Monday, 28 December 2015

Overturn the tables of the money changers

This is the season to be jolly, and I wish all readers a prosperous and rewarding new year! I thank you all for taking the trouble to read Song of Life in 2015.

You will forgive me if I say that our celebration of a new year should be tempered with the knowledge that so many are suffering the consequences of austerity. Poor working people have been made to take the blame for the financial crash and the actions of irresponsible bankers. Their prospects in 2016 are not good.

The NHS is at breaking point. Social justice is being eroded. The social care system is crumbling.  2016 will be the year when local taxes will rise to pay for government cuts - more families will lose their homes.  There will be more NHS rationing as 'efficiency savings' create post-code lotteries in health care. The poorest local authorities will find the most difficulty meeting social care needs. It is likely that more residential home providers will go bust. Happy New Year!

Christmas and New Year are times for reflection.  For Christians Christmas is a time to celebrate the birth and life of Jesus, and a passage in his story I think is appropriate for our times - and that is Mathew 21:12 and 13:

"And Jesus entered the temple and drove out all those who were buying and selling in the temple, and overturned the tables of the money changers and the seats of those who were selling doves. And He said to them, It is written, My House shall be called a house of prayer; but you are making it a robber's den."

I don't know about being a 'house of prayer', but I do know that the City of London is the centre of global finance where the Gods of wealth and greed are worshipped. Love thy neighbour is changed to beggar thy neighbour.

I am not a soothsayer, but there is one prediction I can make with a fair degree of certainty. The 'robber barons' of global finance will still be plying their trade and taking their ill-gotten gains for many years to come.  Global finance is as little regulated now as it was before the crash. The same 'mistakes' are being made. Growth is being 'stimulated' through increasing household debt. We seem to have learnt little from the financial crash.

Imagine these robber barons in the Dragon's Den making their pitch. "We have come up with a package made of nothing, filled with nothing, based on nothing. We can trade so fast nobody bothers to see that it is nothing. And we can make billions and pay no corporation tax." What an ingenious product! "Everyone will become so dependent on it that nobody will dare say it is nothing, worth nothing, based on nothing. Their pensions will be dependent on it." Such is human ingenuity. 

Meanwhile, there is something absurdly self-defeating about a government seeking to promote 'home-ownership' whilst driving so many out of their homes.

It is as if the government believe its own distorted truth - that putting the economy right is all to do with tackling the deficit.  Sadly it is a narrative that reaped success for the Tories in the general election. But it is a false prospectus, and one Chancellor George Osborne is increasingly unlikely to fulfil.

Where have compassion and social responsibility gone?

Whilst the poor and disabled are being driven out of their homes by austerity,  we now find that five large banks paid no corporation tax last year.  That is a disgrace. Despite making billions in profits they paid zilch! The robber barons rule! They don't need to understand the difference between 'lawful' and 'ethical'. If they can find a way, any crack or crevice, they will worm their way into it to escape social responsibility.  They are literally taking us to the cleaners. 

We need a new politics with a new economic and social strategy.  An economy that doesn't simply 'grow' but has social objectives, and where economic success is judged not by increased wealth but by social wellbeing.

We need to put society back at the heart of our economy and not follow blindly an economic strategy predicated on greed and selfishness.  We need an economy with a clear set of social and environmental priorities.

Tony Blair was wrong when he said simply 'education, education, education'. It was a great soundbite, but really what we need is 'education, health and social wellbeing'.  It isn't such a good soundbite, but it is the foundation for a strong economy.

In the three decades following the Second World War, full employment was adopted as an objective. Government acted to clear the old Victorian slums and build new homes.  The State invested in health care and created the National Health Service.  The Welfare State was developed and with all this massively increased public spending, the national debt, which was at a historic high...fell. The debt was paid off!

Yes, it fell.  The economy had ups and downs, but it grew. Increased spending on eduction created a skilled workforce. Increased social spending increased wellbeing. A healthy workforce is a productive one.  This is not to say that all was perfect. It was not. Poor industrial relations and restrictive practices bedevilled production and reduced competitiveness.

Industry after Industry collapsed through the late 1970s and 80s, and the industrial decline continues. It laid waste to so many parts of Britain and these areas continue to suffer deprivation now. Our economy became distorted and reliant on London's position as the Capital of global finance. We import what we should be making.

Yet, the answer to the failure of rampant global finance cannot be found simply by going back to the 1970s.  This is the challenge Jeremy Corbyn's Labour Party faces.  It needs a new narrative - a new set of clothes.  Above all it needs a coherent economic and social strategy, and the truth is it doesn't yet have this.  Let us hope that in 2016 a new narrative gains credence.

We need to overturn the tables of the money changers. But we cannot do that with anger alone. It needs new policies that work with business to meet clear social and environmental objectives.  We need to develop our local economies, working with businesses to harness local potential and resources.  Such a strategy isn't anti-business. It is pro-business. Business harnessed to local needs and social objectives - creating coherent local economies - developing infrastructure, creating jobs. Local authorities, businesses, environmental groups, communities, all working together with clear plans to promote clean and socially responsible growth.

We can no longer go on exporting our carbon pollution through massive imports of manufactured goods, and then claiming we are meeting our carbon targets. When we take account of imports, we are amongst the largest polluters. Currently, meeting 'our' targets is a charade that puts the planet in jeopardy.  I have little faith in the 'agreement' at the Paris climate summit this year.  Only time will tell if we can grasp the nettle to genuinely reduce our carbon footprint. To do so we need an antidote to globalised capital.

So, here is to 2016. I don't have all the answers, but I hope you will continue to join me in 2016 in searching for some of them.  

Friday, 18 December 2015

The case for mandatory folic acid fortification?

The UK’s failure to fortify flour with folic acid has caused around 2000 avoidable cases of neural tube defects since 1998.  This is the conclusion of research published online today in the Archives of Disease in Childhood.

The researchers say that the UK should now follow the lead of the US and 77 other countries  in legislating for mandatory fortification of flour to curb the associated toll of fetal and infant death and disability.

Folic acid is a B vitamin which is vital for the formation of red blood cells.

The UK has rightly been cautious about making 'medicines' or dietary supplements mandatory.  In medical ethics we emphasise autonomy and the right to make decisions about one's health and treatment. Autonomy is a fundamental principle of modern medical ethics.  It sets a high ethical threshold, and a key concern must be that the benefits of mandating medicine should be sufficient to breach this fundamental principle.

To a large extent this is a utilitarian ethical calculus, the balance of benefits and potential harms, but there is another fundamental issue, and that is the extent to which the state should discharge a duty of care on behalf of those who cannot make decisions about their lives - in this case unborn children.

In relation to the ethics of mandatory fortifying of bread with folic acid the real question is whether it is necessary to discharge a duty to protect the unborn child.  If current strategies are failing, then we have a duty to consider other approaches.  These authors present convincing evidence that the current strategy isn't working.

We are dealing with appalling consequences. Neural tube defects, which are birth defects of the brain, spine, or spinal cord, include spina bifida, anencephaly, and encephalocele which can be profoundly disabling conditions.

In 1991 the UK Medical Research Council Vitamin Study showed that a supplement of folic acid taken before and during early pregnancy cut the risk of neural tube defects by around 72%.  That is a big difference.

The problem is that it is difficult to achieve a high enough level of folate from diet alone, so taking supplements or eating foods fortified with folic acid is a sensible option for women intending to become pregnant. It is the recommended option for women about to become pregnant.

In 1992 the Department of Health in England advised women to take folic acid supplements before pregnancy to reduce their risk of having a baby with a neural tube defect.  The problem is, as the study showed, most women don’t take them.  Another problem is that women don't necessarily know they are going to be pregnant, and sometimes they don't know initially that they are pregnant - so they don't take the supplement from the right time.

The current recommendation is that every woman considering pregnancy, and up to the 12th week of pregnancy is advised to take a folic acid supplement, or pregnancy specific vitamin supplement providing 400μg every day,   and that they should eat a diet rich in folates and folic acid from foods naturally containing the vitamin or from fortified foods.

But even with these recommendations, many women do not take folic acid supplements in early pregnancy, and it is argued that routine fortification of flour with folic acid is a simple way to increase folic acid intake for everyone.

Many countries have introduced mandatory fortification of flour with folic acid, resulting in  significantly reduced  numbers of neural tube defect births.  So why has the UK been so cautious?

The UK has been cautious in recommending this for a number of reasons. Firstly, although folic acid supplements can correct the anaemia caused by vitamin B12 deficiency, this masks the ongoing damage to nerves caused by B12 deficiency until irreversible nerve damage occurs. Older people are most at risk because uptake of vitamin B12 from diet reduces with age.  There is also conflicting evidence that folic acid might increase the risk of colorectal cancer in older people. This then is a balanced judgement of potential harms to some of the population against the proven benefits in pregnancy outcome.  There is, however, little evidence for this potential harm.

There is little evidence from countries with mandatory folic acid flour fortification that more people have developed nerve damage as a result of vitamin B12 deficiency since the flour had been fortified.

Thus, a key question is whether it would it make a fundamental difference if the UK followed some other countries in making folate-fortified bread mandatory. The answer from this study appears to be a resounding yes.

The authors of the study have estimated the number of pregnancies with neural tube defects that would have been prevented had the UK opted to fortify flour with folic acid in 1998—the year that the US adopted this policy (140 µg of folic acid per 100 g of cereal grain).

They used data on the number of diagnoses of neural tube defects and associated terminations of pregnancy for the period 1991 to 2012 from EUROCAT, a European network of registers that track birth defects, which includes the British Isles Network of Congenital Anomaly Registers (BINOCAR).

The prevalence of pregnancies with a neural tube defect during this timeframe was 1.28 per 1000 births. Most (81%) of the affected pregnancies were terminated.

But unlike the USA, there was no significant change in the prevalence of pregnancies with a neural tube defect in the 14 years between 1998 and 2012, nor were there any significant changes in the prevalence of spina bifida, anencephaly with or without spina bifida, or encephalocele, when analysed separately.

The researchers estimated that there would have been 2014 fewer pregnancies with a neural tube defect in the UK had the US policy been adopted: 1798 fewer in England and Wales; 152 in Scotland; and 64 in Northern Ireland. This equates to an estimated fall in prevalence of 21% between 1998 and 2012, they say.

In the USA, the prevalence of pregnancies with a neural tube defect has fallen by around 23% since 1998, and in Chile, where the level of flour fortification is even higher, at 2.2 µg/100 g, the prevalence has fallen by 36%.

“The failure of Britain to fortify flour with folic acid has had significant consequences,” say the researchers, who emphasise that its addition is “remarkably safe,” with fears that fortification might increase the risk of cancer not substantiated by the evidence.

The longer Britain holds back on this cost effective mandatory supplementation, the more affected pregnancies there are likely to be each year—around 150, nearly all of which would result in the birth of severely disabled babies, if the parents choose to go ahead with the pregnancy, they warn.

The researchers compare the current situation with thalidomide, which resulted in the births of 500 people with disabilities in the UK.

“Justifiably, steps were introduced to immediately halt the epidemic, and regulatory precautions were introduced to avoid another similar epidemic,” they write. “Unfortunately, no such sense of urgency has been applied to the prevention of spina bifida,” the authors say.

“It is a public health failure that Britain has not implemented the fortification of flour with folic acid for the prevention of spina bifida and other [neural tube defects],” they write. This failure “has caused, and continues to cause, avoidable terminations of pregnancy, stillbirths, neonatal deaths and permanent serious disability in surviving children,” they conclude.


Saturday, 12 December 2015

NHS 'winter crisis' due to Tory cuts.

The 'winter crisis' in the NHS is a crisis of the government's own making. It is the result of the real cost of the £20 bn efficiency savings forced on the NHS. This is the truth behind the headlines of bed-blocking. The bed shortage is because we don't have enough beds to cover increased demand over the winter.

This is the reality. OECD figures show that in England and Wales there are just 2.95 beds per 1,000 people. This compares with 6.37 in France, 7.65 in Austria and 8.27 in Germany. And before the Scottish Nationalist Party pipe up, the Scottish Government figures show their figure is down 21% compared to 2004. But England and Wales are way behind the 4.95 beds per 1,000 in Scotland. Nevertheless, Scottish hospitals have shed beds at a faster rate than almost anywhere else, with more than 5,000 disappearing in just seven years. In North Wales more than 400 beds have been lost over the last five years.

In response the government would say it is due to “ongoing changes in the way modern health care is delivered”. That is a euphemism for 'efficiency savings' - it means cuts in front-line services and it means a bed shortage.

The government will say that the NHS is 'treating more people faster than ever before'. This is a euphemism for getting them in and shipping them out fast but often before they are fully recovered, and a costly revolving door as patients are readmitted in A&E. This revolving door practice is not good medicine. It is costly and inefficient and delivers poor care.

English hospitals have lost 5 beds every day of David Cameron's tenure at number 10 Downing Street.


So as we wring our hands again at the 'winter NHS crisis' we will be told it is due to an 'ageing population' and a lack of 'care beds'. In the sense that this is true, it is only partly so because it is in the main due to cuts. Those cuts are the result of the £20 bn efficiency saving imposed on the NHS. Think what a further £22 bn will do because that is what the NHS are asked to find in the next five years. This madness should stop!

Monday, 7 December 2015

More for less is no solution in the NHS

The audacity of Chancellor Osborne knows no bounds. Having starved the NHS of much needed funding he now says: 'We have a clear plan for improving the NHS. We’ve fully funded it.'

Nothing could be further from the truth.

Britain's National Health Service is in a financial crisis with more Hospital Trusts in deficit and creeping privatisation eating at core provision.  Despite the government giving £3.8 bn funding up front, NHS England is expected to find a further £22 bn in efficiency savings over the next five years on top of the £20 bn already found. As shown in a previous article, this is affecting front line services with increased waiting times and bed shortages.

Mr Osborne wants to avoid last Christmas' headlines of an NHS unable to meet demand.

Last December, NHS England figures show, the numbers of patients waiting on trollies in A&E trebled from just over 13,000 to 38,848.  Now, the government is trying to avert another Christmas crisis by providing extra emergency funding. All well and good, but it is crisis management of a health service brought to its knees through lack of funding.

We are often told that the strains on the NHS are the result of an ageing population.  It is certainly the case that the proportion of older people has increased and will be increasing.  In 1991 15.9% were over the age of 65 -  now it is more than 16.5% (the 2011 figure). But this isn't the real cause of the NHS A&E crisis.  The NHS is under strain from inadequate resources and from efficiency savings that have eaten into the numbers of beds available. The NHS has been striving to do too much with less, for that is what efficiency saving means.

One of Mr Osborne's commitments is for cancer testing within four weeks. This is welcome if it can be achieved.  NHS England unveiled plans for the new cancer strategy back in February, with a view to saving ‘at least 8,000 lives a year’ through the 'early diagnosis drive'.  We can hope this works, but there are warnings that the system is already overloaded.

It should also be an imperative to ensure that the diagnoses are robust and safe.  There are suggestions this would require a doubling of the number of radiologists.

Earlier this year the Royal College of Radiologists reported that radiology departments "are under considerable pressure to minimise the number of unreported studies while facing additional challenges including shortages of consultant radiologists, other resourcing issues and ever increasing demand."

There is a chronic shortage of radiologists in the UK.  Comparison with other european countries is stark. With 48 trained radiologists per million population the UK has half the numbers in Germany (92) , Spain (112) and only a third of the number in France (130) .  The number of scans performed in the UK remains significantly below those in other countries for most tests. 

It is no surprise then that in some trusts there are tens of thousands of X-rays and hundreds of CT and MRI investigations waiting more than 30 days for a report.

Radiology departments are increasingly outsourcing their reporting work to commercial private companies and/or using expensive locum agency staff to minimise any backlog in unreported studies. These are expensive solutions which impact considerably on NHS finances. In the end it is unsustainable. 

Meanwhile, the chances of surviving five of the most commonly occurring types of the cancer in the UK trail at least 10 years behind many comparable European countries. One of the worst examples is lung cancer.  Survival has certainly improved. Where only 7% of patients survived in the 1990s in the UK this improved to 10% a decade later but this was still behind the 14% survival rate achieved in, for example, Austria in the 1990s. Almost 18% of patients diagnosed with lung cancer in Austria survive - twice the rate in the UK. The proportion of people with lung cancer dying within a year of diagnosis in the UK was 70%, compared with 65% in Denmark, 61% in Norway and 56% in Sweden.

In the past decade the survival rates for breast cancer is 81% in the UK – a level exceeded 10 years ago in Sweden, France and Italy.  It is clear that more can and should be done. 

Macmillan Cancer Support say that too many people are diagnosed too late, are shown a lack of compassion during their care and feel abandoned after treatment.  They call for more focus on reducing late diagnosis,  on prioritising the patient experience alongside clinical matters,  and more effort to enable patients to spend their final days in the place of their choosing and with free social care.  

At the beginning of this year NHS England announced that sixteen life-extending cancer drugs would no longer be available to patients in England after the NHS announced it would not pay for them through the Government’s flagship Cancer Drugs Fund. This was a drastic bid to cut costs, saving £80 million from the budget.

Meanwhile Osborne gives with one hand but takes out more with the other. An NHS under pressure to find a further £22 billion in efficiency savings by 2020 is unlikely to be able to meet the ever growing targets placed on it - more for less is not a solution. 

Thursday, 3 December 2015

Let's break the cycle of poverty and disease

The House of Commons Health Committee has called for urgent action on childhood obesity.  Childhood obesity is increasing at an alarming rate. One fifth of children are overweight or obese by the time they start school, and this increases to one third by the time they leave primary school.


The cost of childhood obesity is an example of the short-sighted madness of Osborne's austerity programme.  The consequences of obesity on health will cost more in the long run than any saving he makes by cuts in welfare and support.  It is a foolish strategy.  The Health committees report demonstrates this in stark terms.




The government spends just £638 m per year on obesity prevention, yet the cost to the NHS of obesity and its consequences coupled with type 2 diabetes is a staggering £13.9 billion each year, and the cost to the economy is estimated at £27 bn.

The Health Committee  are right when they say that childhood obesity is a complex problem which will need action across a number of areas.  They are right to highlight excess sugar consumption, and they are right to call for urgent action to deal with it.  They call for:
  • Strong controls on price promotions of unhealthy food and drink
  • Tougher controls on marketing and advertising of unhealthy food and drink
  • A centrally led reformulation programme to reduce sugar in food and drink
  • A sugary drinks tax on full sugar soft drinks, in order to help change behaviour, with all proceeds targeted to help those children at greatest risk of obesity
  • Labelling of single portions of products with added sugar to show sugar content in teaspoons
  • Improved education and information about diet
  • Universal school food standards
  • Greater powers for local authorities to tackle the environment leading to obesity
  • Early intervention to offer help to families of children affected by obesity and further research into the most effective interventions.
All these measures are necessary but insufficient unless the underlying social problem is also addressed.

Child poverty matters - it matters a great deal because it represents a crucial link in the causes of poor health.  Furthermore, childhood obesity is a major consequence of poverty.   It we really wanted to tackle childhood obesity we would also want to tackle childhood poverty.  But let's examine what that means.  It means ending poverty.  It means creating fairness in the distribution of wealth and opportunity. It means ending poverty wages and insecure jobs.  It means creating an economy with social objectives.  It means not only being tough on childhood poverty but also being tough on the causes of poverty.  We must stop the madness of austerity.

Mr Osborne in his autumn statement boasted about being 'the builders' - 'we are the builders' he declared.  But what has he built? He has created an economy predicated on poverty wages and insecure jobs.  If we are serious about tackling poor health we would end austerity.  Investment in health and social care is the best investment for future growth and prosperity - it creates a healthy, skilled, aspirational workforce.  Social and personal aspirations go hand in hand in creating a prosperous and fair society.  The aspirational generation of Thatcher's Britain was forged in the post war welfare state, not in the 'free' market neoliberal myth of opportunity.  Social housing, better education, better health, better support - these were the foundations of fair growth and prosperity.

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.  Maternal nutrition matters. Maternal poverty matters. If we really wanted to break the cycle of poverty and disease we would not be pushing more people into poverty through austerity.

It is unfair that the poorest should suffer for a financial crisis that was not of their making. It is incredulous that we should make children suffer for it. But it is also bad economics.  The government should act on the recommendations of the Health committee but it should also stop driving poverty through austerity.  We need a strategy that sees the health of people as a vital investment and not a vicarious outcome of 'devil take the hindmost' market forces. We need a government that builds society, not one that destroys it.

Tuesday, 1 December 2015

The Emperor has no clothes

John Berger wrote that the poverty of ‘our century’ (he was referring to the 20th Century) is unlike that of any other. ‘It is not, as poverty was before, the result of natural scarcity, but a set of priorities imposed upon the rest of the world by the rich.’ He went on to say that the modern poor are not pitied but held responsible for their own condition.

We see this writ large in Cameron's austerity Britain.  The poorest are not only being made to pay the price for the failings of an irresponsible financial system, they also have been stereotyped as undeserving, work-shy and dependent on benefits.  It is a stern message without hope -  more poverty will drive them to help themselves out of poverty.  The Secretary of State for Work and Pensions has said as much - he wants to make those on benefits 'better people'.  It is as if the poor must be saved from themselves, or from 'welfare dependency' by a 'cold turkey' of reduced benefits.

So what of the banking crisis? Have lessons really been heeded? It barely gets a mention in the political narrative.

For a brief moment after the banking collapse there was a focus on the sins of the bankers, or a concern about the banking system.  A bit of fuss was made about bankers bonuses and about 'rogue bankers', but such a narrative itself avoided the real issue - the financial system itself.

The financial system remains politically unchallenged.  But a new economic and social narrative is desperately needed.  We really need to ask what the financial markets are for - or who they are for. 

For the best part of the last five years the focus has been on 'cutting the deficit' by cutting welfare.  It has been an amazing political trick - to rewrite the narrative.

Welfare did not create the financial crisis, but the poorest and most vulnerable are being made to pay, and as our social infrastructure in health and social care collapses  - starved of funding - we are asked to believe that more private equity is the answer.

It is a spiral down as social provision is removed to be replaced by private provision -  or the provision isn't replaced at all.  It is all about 'reducing the size of the state'.  

But consider the global position.  How can it be that so many live in poverty and in poor health when the world has the capacity to produce so much food, has the potential to ensure families are decently housed and educated, and has the capacity to raise the health and wellbeing of all? Why this doesn't happen is in large part because of the absence of political will. But there is another more important reason.

The answer is that the algorithms of our financial markets have no social or environmental imperative. 

The one thing politicians cannot do is bring themselves to tell us the truth about our financial system. They have placed so much faith in it - worshiped at the Alter of neoliberal 'free' market economics. They have given up their free will for a belief in the inevitable economic imperatives of free financial markets - God is made in the image of an algorithm driven market and the assumption of human selfishness.  There is no social objective - only that of accumulating wealth.

Many of us are familiar with the cautionary story by Hans Christian Andersen about two weavers who promise an emperor a new suit of clothes.  The suit he is told is invisible to those who are unfit for their positions. If they can't see the invisible suit then they are stupid, or incompetent.  The Emperor believes it, and his courtiers are too afraid to tell him the truth.

When the Emperor parades before his subjects in his new clothes, no one dares to say that he is naked until a child cries out, "But he isn't wearing anything at all!"

The neoliberal myth of ‘free markets’ is like the emperor without clothes. The global financial markets strut their stuff, buying and selling nothing at all to the tune of trillions of dollars. Imaginary boxes of nothing at all - or perhaps hope, greed, envy. The global markets work as long as we believe the boxes are full of something, or could be full of something. But they are not. They are empty. The greatest trick of capitalism is that it has valued nothing and sold it. It trades in it day in and day out, accumulating 'wealth'.

Yet so much of this activity creates no real wealth at all, no real goods or services. Only some 3% of the trillions held by British banks is ever invested in real production – in real businesses providing goods and services that we need. If we counted up the value of all the goods and services - the ‘real’ wealth -  it would amount to only a fraction of the ‘value’ of the transactions in the financial markets. It is a trade in imaginary wealth.

Politicians, like the emperor’s subjects, pretend that this isn’t so. But it is. And even when the system breaks down, they invest considerable effort in recreating the myth and refitting a new set of invisible clothing. Global financial capital rules, and only the ignorant would suggest otherwise.

Mr Osborne uses the term ‘we are the builders’. Sadly we are not. Where once we produced goods, we now import them. We have a massive balance of trade deficit with the rest of the world. London is the centre of the neoliberal myth, we depend on pretending the Emperor has clothes.

Global computer models, based on the worst instinct of mankind, selfishness, make thousands of transactions every second.  We have handed our financial well-being over to computer models, but the mathematics is not without its assumptions. They are philosophically and politically grounded. 

So how has this come about? The answer is the separation of the economy into two domains - the financial and the real.  Both should be part of an organic whole, but the financial markets operate with little regard for the real economy and with sparse regard for real need.

The real economy needs social objectives. It needs a healthy, skilled workforce. It needs infrastructure to work and it needs a stable local environment - the real economy needs social objectives as an integral part of the economy. But it also needs finance.

The global financial market trades largely in 'derivatives', futures, swaps - or some other terminology for the empty boxes -  the value of which are only loosely related to a real asset. It has little capacity for social or environmental strategy.

It is a massive gambling casino with betting on, for example, interest rate futures, where traders speculate on the future direction of interest rates, or the rise and fall of commodity prices or exchange rates.  It will bet on any aspect of 'price' that will move.  But rarely engages in building bridges or restoring the environment or tackling poverty.

But what about growth? Doesn't that help?

Relying on growth to reduce poverty is at best rather inefficient. How much growth does it need? In spite of massive 'growth' the poor receive but crumbs. Yet it has been the curse of the poor for so many decades that government has promoted 'growth' as a strategy.

The more wealth we can produce, the story runs, the more it will benefit the poorest.  The idea that there could or should be a social strategy for apportioning such growth appears to have been lost somewhere in the late 1970s - redistribution became a dirty idea, in part because it would mean taxing the 'wealth makers'. Taking from the rich and giving to the poor we are led to believe would be a disincentive to the 'wealth creators'.

Relying on growth alone without  strategies to achieve social redistribution of the benefits of that growth is unlikely to be effective. If our objectives are to make poverty history or to make the world a less unequal place in which to live, then we need something different in the way we do things. 

We need a new political-economic settlement that puts social objectives at the heart of economic activity.  This requires politicians, businesses and finance to work together to achieve fair growth. We need growth, not for its own sake, but for a purpose - the purpose of increasing well-being for all whilst protecting the environment on which we depend.  The Emperor needs a real suit of clothes.  


Thursday, 26 November 2015

"Efficiency saving" has undermined the NHS

The government has announced extra money up front to avoid a crisis in the NHS. That much is welcome news. But it comes with a further tranche of 'efficiency savings' of £22 billion. This is on top of the savings of £20 bn over the last five years. But what have been the consequences of these 'savings', and where has the money gone? If savings were made, then why are so many Trusts in financial difficulty?

Last year the House of Commons Health Committee warned that the targets of these savings were 'unsustainable' after hearing evidence from NHS finance directors. The committee also criticised the Government's lack of transparency over how the money saved had been used, raising the issue that the Department of Health handed back billions of unused NHS budget back to the Treasury each year.

It certainly begs the question of why so many Trusts are in deficit when they have made such big efficiency savings.  What is the truth behind these savings?

Efficiency savings conjures up images of making 'cuts in the back room' or improvements in  'back office efficiency'. We are supposed to believe such changes would be improvements and won't affect front line staff or front line services. On the contrary we are supposed to believe these will improve patient care.   It is argued that the front line services could be provided more efficiently and effectively.  But what is the reality?

Let's be clear what efficiency savings really mean. It is about meeting rising health care needs from the same resources.  That means  more operations without adding more operating theatres, surgeons, anaesthetists and nursing staff. 

It also means freeing up beds quicker. 

That is the bottom line of 'efficiency' savings - and it is also one reason why the NHS is in crisis, with bed shortages and increased waiting times, and with NHS Trusts in deficit.

Efficiency savings means freeing up beds through earlier discharge. It is also what has led to the charge of 'bed-blocking' levelled at sick patients. This has had appalling consequences.

As I referred in a previous article, a report by Healthwatch England found that premature discharge from hospital creates a costly 'revolving door' with one million patients readmitted to hospital within 30 days of being discharged. Readmission into A&E costs the NHS a staggering £2.4 bn a year.  This is not 'efficiency' - it is carelessness.

What is rarely told is that the 'bed shortage' is a  result of 'efficiency savings'.  

From the outset of the Quality, Innovation, Productivity and Prevention - (QIPP) the overarching efficiency savings process - 'enhanced recovery' was targeted with the potential to save 200,000 bed days.  The idea was to enhance the patient experience by making a quicker recovery to care.  What it often means is transferring the cost of sick people onto the care budget. 

The Daily Mail provided examples of this cruelest kind of 'efficiency' in a report last year. 

"Sharon Mounter felt a wave of rising panic when the nurse told her that she was being discharged from hospital.

The 35-year-old events organiser from South London still had a fever, and felt so weak and dizzy she could barely sit up in bed. But the nurse insisted in a kind but firm manner that she was well enough to leave, adding: 'We need your bed.'

Sharon had been in hospital for almost a week after being admitted with a high temperature and 'unbearable' joint pain.

Doctors attributed it to a flare-up of her lupus, an autoimmune disease that causes the immune system to attack its own tissues and triggers fatigue, pain and skin rashes."

Sadly this is not an isolated case - and nor was Sharon an elderly 'bed-blocker'. 

A survey by Healthwatch England found that more than half of NHS hospitals do not record whether a patient has a safe home to return to before discharging them.

But what is the real outcome? The outcome is added burdens on families and local authorities with care costs.  Families being given two days notice that their relatives must be moved into care to free up a bed. 

This is why we ended up with NHS Trusts threatening legal action on 'bed-blocking' patients. It was a game of shifting the blame.  We are supposed to believe the bed shortage is the result of 'people living longer'.  This is clearly nonsense - a smoke screen to cover what is really causing the problem. We haven't suddenly started living longer! Yet the 'bed-blocking' problem developed over the course of a year or two.  We need only ask why to realise that it isn't because people are 'living longer'. 

No, it was driven from within the NHS itself. It was part of the 'efficiency savings'. The idea was to get patients into care quicker. But 'care' was the loser as cold calculation took over from compassion. The NHS and the Care 'system' play a game of musical chairs, or perhaps I should say beds, and it is patients and families who suffer the consequence. 

Wednesday, 25 November 2015

Osborne fails on social care

George Osborne has missed the mark on tackling the growing social care crisis.  He has failed to provide a coherent analysis or strategy to deal with the problem. We need a national strategy.

The crisis in social care funding was recognised by the Chancellor of the Exchequer  in his autumn statement today.  He announced that local authorities will be allowed to increase council tax by up to 2% to help meet social care needs.  This appears a good move. It is a step, but much more is needed.

It is anticipated that the new social care "precept" in council tax of up to 2% will allow local councils to raise £2bn for social care. It is good that more money will be available,  but I anticipate a fundamental problem with this approach.

Not only does need varying geographically, but those areas with the greatest needs are not those with the greatest potential for raising revenue. It may exacerbate the north-south divide in resourcing.

Data from the ONS and from the National Audit Office show that local social, economic and demographic factors lead to variation in the level of social care need in each local authority. Thus, there are more self-funded residents in care homes in the South than the North.   In the Northeast, almost 80% of those in care homes are funded by the local authority.  In the South that figure can be less than 50%. There will be large variations across local authorities - the areas where there is the greatest need may not be those where there is the greatest potential to raise income through the new precept. 

Local authority spend on care depends on local need, but also on local policies and priorities. It depends also the local authority’s commissioning and financial management skills. But as the National Audit Office has pointed out,  many factors are outside a local authority’s control or can only be influenced long term or by national economic and social policies.  

Need for care is also linked to an adult’s health, the quality of their housing and the effectiveness of other support and services, in preventing needs developing. This again is why the burden falls disproportionately in some areas and less in others.  The poorest areas of the country are also those with the poorest health and the greatest social care needs. 

Demand for care varies according to need, availability of informal care, quality of formal care services, voluntary provision, health, housing and other services, plus individuals’ wealth, choices and expectations. These factors combine to create different levels of demand in each local authority area.  Meanwhile the distribution of wealth and the ability to pay for services is disproportionately distributed.  It is an old problem - the areas of greatest need are the less able to meet that need.  This is why we need a national approach.  

Allowing local authorities to raise a precept is not in itself bad.  It is a strong move to devolve local decision making and priorities.  That much is right.

But we need more. If there is to be a hypothecated approach then we need this at the national level too.  We need a national strategy not simply throwing the burden onto cash-starved local authorities. Just as we have a national health service, so we need a national approach to care. 

Osborne has failed to address the problems of care nationally. We need a joined up care and health system responsive to need and not a post-code lottery in care dependent on a local authorities ability to pay.

We need resources fairly distributed so that the areas of greatest need do not fall short of meeting those needs.  Much more needs to be done to address the issues.


Monday, 23 November 2015

Let's stop blaming patients for lack of care

'Bed-blocker!' This is the new, dangerous and pejorative stereotype in the NHS - elderly people with nowhere to go, occupying hospital beds. Sadly, it has become an accepted story.  It is a cover for the reality of a shortage of beds and an NHS in crisis.

In its simple form,  'bed-blocker' is an epithet used to suggest someone occupying a bed in a hospital unnecessarily,  preventing someone else receiving necessary treatment. It presupposes they are not ill and don't need treatment.  Yet evidence shows that many are sent home seriously ill.  Yet, 'Bed-blocker' has now entered our pejorative lexicon.

Earlier this year it was revealed that more than one million hospital bed days were lost because of 'delayed discharges' during the preceding 12 months.  Now, that is a lot of hospital bed time! It represented an increase of 20 per cent in a year, and it is now at a record level with a cost to the NHS of £287m.  Headline news.  So what is the reality behind this problem?

First we should ask how it could have risen by 20% in one year, given that the proportion of the population who are elderly didn't rise by that much.  Many are living longer, but we are not ageing any quicker! So what could have happened? It suggests it is an effect and not a cause of a deeper crisis.

Acute care is largely provided in 164 NHS hospitals, free at the point of use for patients and ultimately paid for through general taxation.  Long term care is provided in over 18,000 public or private care-homes and 60% of residents make at least some payment for this care, with means tested subsidies provided to poorer residents by their Local Authorities.  But long-term care is often also provided at home and at considerable cost to the patient and their families.  Shifting the criteria for discharge shifts the financial burden from the NHS to the family.  Shifting patients out too early has introduced a dangerous form of rationing in the NHS. 

Bournemouth Hospital thought the problem of 'bed-blocking' was so bad it threatened to take legal action against 'bed blockers', saying too many families are refusing to take elderly relatives home when they are 'fit to go'.  It is a blame-shifting  game. A dangerous game of musical beds where patients are discharged to make way for others in a lengthening queue. 

A spokesperson for Bournemouth Hospital said new patients, sometimes seriously ill, may have to wait in corridors or on trolleys in Accident and Emergency, while routine operations are cancelled because there are simply not enough beds.  Healthwatch Dorset, reported that many sick patients felt pressured to leave hospital before they were ready.

All this suggests that a cold calculation of cost and targets is taking over from care and compassion. - a quick fix for a squeezed NHS at the cost of patient care.

A report by Healthwatch England found that premature discharge creates a costly 'revolving door' with  one million patients readmitted to hospital within 30 days of being discharged. Readmission into A&E costs the NHS a staggering £2.4 bn a year.  It demonstrates that something isn't right about the 'bedblock' story.

There is little doubt that care is in crisis, with savage cuts making provision difficult. But we should be wary of a new narrative suggesting patients or families are wickedly occupying NHS bids - a division between the deserving 'genuinely' sick,  and the undeserving who are not really ill.  It is far too simplistic -  an assumption that the problems of the NHS are substantively due to lack of community-based or home care.  At best it is only part of the story.

We should consider that the burdens on care in the community or at home may also result from failure of an insufficiently resourced NHS - a game of pass the parcel of costs - a game of passing the patient from pillar to post. It is a political story, as much as a social one.  It is a story of political failure. Failure to invest in health and care, and failure to develop a joined up coherent health and care service.

Officially, bed-blocking occurs when hospital patients are ready to be discharged into long-term care but no place is available.  It raises two problems: 1) the decision on when a patient is 'ready to be discharged' and 2) where they are to be discharged to.  The first requires clear criteria on deciding when a patient should be discharged and it raises issues about how these criteria are applied in any given circumstance.  It should at the least consider the potential for effective nursing care at home compared to that provided by the hospital.

What is genuinely in the interest of the patient? Simply discharging a patient without consideration for how best care can be provided would a dereliction of a duty of care. It is the worst kind of rationing of health care when the service says one ill patient is less deserving than another.  The demands on a health service in crisis are being met by discharging patients too early.

Data from Healthwatch England suggest that the criteria for 'ready to be discharged'  is itself changing with the added pressure on a financially squeezed NHS.

Healthwatch England say many patients feel stigmatised during their care. Some of the most vulnerable people are being discharged with insufficient support. Consider the circumstance where an elderly relative is taken into hospital in a critical condition but there is little the doctors feel they can do and the family are then given just two days to arrange the 24 hour care needed at home - nursing care that will run into tens of thousands of pounds.

So what evidence is there that 'bed-blocking' is caused by a lack of residential care?

Study for the Centre for Health Economics showed that the problem is more acute in Local Authorities where there is a smaller supply of long-term care beds and where prices for these beds are higher. But the study also showed that although increases in the supply of long term care beds reduces delayed discharges, the effect is modest and concluded that an increase in the supply will not significantly reduce overall costs across hospital and social care sectors. 

The BMA Patient Liaison Group  in 2013 said it was aware of 'growing concerns' among patients about inappropriate discharges from hospital.  It concluded that the challenges posed by trying to co-ordinate services between hospital staff, transport providers, GPs and social care staff may be exacerbated by those involved not seeing the whole picture and not being aware of the impact that their contribution can have on other aspects of the process and on the patients and their families. 

If there is a problem with beds, it is only part of a broader picture.  It is not a cause but an effect of an NHS and social care crisis. That crisis stems from inadequate funding and a poorly joined up care service. Let's stop the pejorative language. Let's stop talking about 'bed blocking' and consider how best care and support can be given to vulnerable patients. 

Sunday, 22 November 2015

Privatisation threat to NHS grows.

The Tory government has pushed the NHS into a deficit crisis and sewn the seeds of its destruction. Am I being melodramatic? Possibly, but let's consider what has been happening in the NHS over the last five years.

The NHS is under threat not simply from underfunding and deficits but also from a growing privatisation of its services. Figures released last year  by the BMA showed the extent of creeping privatisation in the NHS under the Health and Social Care Act 2012, and it is set to get worse.

The investigation by the BMA found that a third of NHS contracts have been awarded to private sector providers since the Health and Social Care Act came into force.

The BMA council chair, Dr Mark Porter, said at the time:

“These figures show the extent of creeping privatisation in the NHS since the Health and Social Care Act was introduced. The Government flatly denied the Act would lead to more privatisation, but it has done exactly that.

"Enforcing competition in the NHS has not only led to services being fragmented, making the delivery of high-quality, joined-up care more difficult, but it has also diverted vital funding away from front-line services to costly, complicated tendering processes.

"What's worse is that there isn't even a level playing field as private firms often have an unfair advantage over smaller, less well-resourced competitors, especially those from the NHS and social enterprises. To undo this damage we need an honest and frank debate about how we can put right what has gone wrong without the need for another unnecessary and costly top-down reorganisation.”

Outsourcing is a specific intent of this government. It isn't simply a means to better health care. It is an ideological objective in itself.  As more funding is diverted to outsourced companies, so less is available for in-house provision. It is an asset-stripping by stealth.  Once it is gone, it is gone. The less able in-house provision becomes the more the need for outsourcing to meet growing and unmet demand for services.

We might think this outsourcing doesn't matter.  If the services remain free at the point of use, does it matter who provides it? It is also argued that private companies will introduce efficiency and improve care. But we should remember the nature of a market - the distribution of goods through price. It is the very antithesis of the promise on which the NHS works, which is to provide service free at the point of need.

With increasing waiting times and an NHS starved of funding we are already seeing NHS trusts rationing treatment.  With increased private provision within the NHS, such rationing will produce a two-tiered system with those who can afford to pay jumping the queue for treatment.

It is often pointed out that outsourcing didn't start with the 2012 Act. The last Labour government used private provision to 'extend choice'. It was an integral part of Blair/Brown approach to NHS reform. So what's new?

Agreement on the extent of private provision is difficult to find.  The government insists that no more than 6% of the NHS budget goes on private provision. Others disagree.  A key question is whether it is increasing and by how much.  It is the direction of travel that is the problem, and that direction suggests an ever increasing slice put in the hands of private companies.

Earlier this year the NHS Support Federation campaign group showed that private firms had won £3.54bn of £9.628bn worth of deals awarded in England in 2014 – a win rate of 36.8%. A Labour freedom of information request revealed that private firms have been winning 40% of contracts commissioning groups have put out to tender, worth a total of £2.3bn, only slightly fewer than the 41% awarded to NHS bodies. 

Figures from the Department of Health suggest some £10 billion of the total NHS budget of £113 billion is spent on care from non-NHS providers (not including dentistry, medicines or general practice).

Figures gathered by Unite show that in just three years £7 billion of new NHS contracts have flooded the private health care market – a figure set to soar to £20 billion over the next few years. But it is the hard reality beneath the figures that shows the growth of private provision.

Virgin Care runs more than 100 services across the country, including sexual health services in Oldham, a £120 million contract to run Devon children's integrated health and social care community services, and a £500 million contract to run community health services in Surrey. They also run 358 GP practices. 

Serco has won a £140 million contract to run community healthcare in Suffolk and a £32 million contract to run out-of-hours GP services in Cornwall.  Specsavers - the optometrists and eye wear specialists - has bagged more than 30 NHS contracts to supply hearing aids and community audiology services on high streets across the country. It is one of several private firms approved to provide NHS services under the government's 'any qualified provider' scheme.
Creeping privatisation isn't the only threat. Mr Cameron is determined to put his full weight behind the Transatlantic Trade and Investment Partnership (TTIP), a comprehensive free trade agreement currently under negotiation by officials of the European Union and USA.

The aim of TTIP is to create new markets in Europe for transnational corporations. It will open up all public services, including the NHS, to competition from transnational corporations with the likely result of a further wave of privatisations. TTIP works on the basis that all services are open to privatisation unless they are specifically exempt.  Prime Minister  David Cameron has refused to say that the NHS will be exempt. That refusal speaks volumes. 

With more Trusts in deficit and a further financial squeeze we can expect a greater push from government for services to be provided by the private sector.  The scavengers of private equity are circling our underfunded NHS.

Wednesday, 18 November 2015

Work Capability Assessment undermining mental health

Since 2010 the Work Capability Assessment (WCA), has been used to assess the eligibility of claimants for out of work disability benefit.  In introducing WCA the government claimed it was a measure to get more people back into the workplace and help curb the government’s rising welfare bill, with the implication that many of those on benefits were 'shirkers'.  It was all part of the government's political narrative of 'workers' versus 'shirkers'.

The government were warned by health professionals that the harsher assessments would have major impact on mental health.

At the outset there were problems with the way fitness to work was being made and doubts that those making the assessments would have the necessary expertise and experience to make an assessment of how any particular mental condition impacts on the life of the claimant.

Doctors and disability rights organisations have long voiced fears that use of the tough new criteria to measure incapacity to work is undermining the mental health of claimants.  These concerns were voiced in this blog in an article published two years ago. However, up till now, there has been no hard evidence to substantiate these concerns.

Now new evidence published in the Journal of Epidemiology and Community Health confirms that the introduction of the more stringent test to assess eligibility for disability benefit in England may have taken a “serious” toll on mental health.

Areas with the greatest use of the WCA in assessing existing claimants have seen the sharpest rises in reported suicides, mental health issues, and antidepressant prescribing, the findings show, prompting the researchers to question the wisdom of introducing this policy.

To find out if there was any link between use of the WCA and a rise in the prevalence of mental health issues, the researchers analysed the numbers of disability assessments carried out in 149 local authorities in England between 2004 and 2013.

They looked at local trends in suicide rates among 18 to 64 year olds; antidepressant prescribing patterns; and Labour Force Survey data on self-reported mental health issues among the working population in each local authority.

Between 2010 and 2013, more than one million people claiming disability benefit were reassessed using the WCA.  Furthermore, a higher proportion of people living in areas of deprivation were reassessed, putting added pressure of people already struggling.  The findings of the study are stark.

In areas with higher rates of reassessment, there was a corresponding increase in suicides, mental health issues, and antidepressant prescribing.

After taking account of the impact of baseline deprivation, economic trends, and long term trends in mental health, the researchers calculated that, there were around six extra suicides, 2700 more cases of mental ill health, and an extra 7020 prescriptions for individual antidepressants for every 10,000 people reassessed during this period.

This adds up to a total of 590 additional suicides, 279,000 extra cases of mental ill health and 725,000 more prescriptions for antidepressants across the country as a whole that were associated with the reassessment policy between 2010 and 2013.

This is an observational study, so no firm conclusions can be drawn about cause and effect. None the less, the researchers point out that they were at pains to adjust for other potentially influential factors, and that the observed increases in mental ill health followed—rather than preceded—the reassessment process.

The findings have important implications for the WCA policy particularly as this was introduced without any evidence of its potential impact or any plans to evaluate its effects. A further 1 million people will have been reassessed this year.

As I have repeatedly argued in this blog, the policy raises ethical issues for the doctors involved, given that they have professional and statutory duties to protect the health of patients and the public.  The authors say their study provides evidence  that the policy in England of reassessing the eligibility of disability benefit recipients using the WCA may have unintended but serious consequences for population mental health, and there is a danger that these adverse effects outweigh any benefits that may or may not arise from moving people off disability benefits.

“Although the explicit aim of welfare reform in the UK is to reduce ‘dependency,’ it is likely that targeting the people living in the most vulnerable conditions with policies that are harmful to health, will further marginalise already excluded groups, reducing, rather than increasing, their independence,” they conclude.

Peoples' lives are a narrative. They are not disjointed bits of data. Disability isn't simply a problem confined to the individual as a physical being but also as a social being. The social condition can have as much of an impact as any measure of 'disability'; circumstances can be disabling. How any particular condition affects a person's capabilities may vary with time, with geography and with other physical or mental conditions. In short the way in which any condition can be disabling is complex. Sometimes it is the very complexity that is disabling. Disabilities are most often multifaceted.

The government chose to ignore concerns that assessment was being made by inexperienced staff and that such assessments would have major impact on the mental health of claimants. 

In evidence presented jointly to the 3rd yearly review of WCA mental health organisations had said:

“We believe that, without expertise in the causal conditions, healthcare professionals are not sufficiently equipped to understand why and how function may be impaired or to elicit the relevant information from an applicant who may have… difficulties in reporting their condition” (joint response from the Centre for Mental Health, HAFAL, the Mental Health Foundation, Mind, Rethink Mental Illness, the Royal College of Psychiatrists and SAMH )

This new evidence supports the contention that tougher disability benefit assessment is taking a “serious” toll on mental health with higher reassessment rate being linked to more suicides, mental ill health, and antidepressant use. 


Tuesday, 17 November 2015

The Ticking Clock of Social Care in Crisis

George Osborne is ripping out the very fibre of our social being and selling it off to the highest bidder.   But as a business model it stinks. Social care is a failing business.  Social care is in crisis.

Earlier this year Age UK warned that the social care system in England is on the brink of a 'cataclysmic' collapse with cuts in funding leaving the system unsustainable.  They warned the government that the 'clock is ticking'.  As a result many families will be facing unpalatable decisions about the support they will need, and where local authority provision fails, the vultures of a rampant private care system will hover. 

You might think that all this could at least be ameliorated through careful planning, but many families find themselves in unforeseen situations when NHS care comes abruptly to an end.  When a relative goes into hospital in a critical condition, but there is little doctors can do so they are returned home with the anticipation that domiciliary nursing care can be provided. 

Families may be given just a few days to make such provision.  In the turmoil and anxiety they are expected to search out care providers, consider the financial implications, make necessary adaptations to their homes, seek advice and finance, and still come to a rational choice about what is needed and how best it can be provided.  The cost is huge.  

Consider also that those having to make such decisions are themselves often elderly if not frail.  They are meant to have choices, but in effect they are given a fait accompli.  Nursing care costs mean that the family faces financial ruin. 

Finding money to foot these bills will, according the Department of Health,  trigger more than 35,000 emergency property sales a year.  The need for a quick sale also leaves families in a desperate situation where property prices are slashed for a quick sale.  Homes may have to be remortgaged to pay for social care provision.  This is the stark reality. These are not exceptional cases. Our social contract has been abandoned. The fabric of that contract, woven over many decades, has been shredded.

The government will say it is because more and more people are living longer.  But that isn't the reason. The reason is that the government has cut, cut and cut provision to local authorities and they have squeezed funding of the NHS so that it also is now unable to cope with the added consequences of failing social care. The need to prevent 'bed blocking' means that the onus is pushed on to relatives having to make domiciliary provision or put their loved ones into residential care, and often with just a day or two notice. 

It is a problem of the government's making, and not simply that we are 'living longer'.  It is the price of austerity. Yet what kind of 'austerity' is it that cuts inheritance tax whilst cutting social provision? what kind of austerity is it that cuts tax on a pint of beer whilst cutting social care? What kind of austerity is it that cuts taxes for the wealthiest whilst others are ruined by social care costs? It is unfair ,unjust and bad economics.

Despite Tory promises made under the previous coalition, tens of thousands of people will have little choice but to sell their homes to pay for social and domiciliary health care.

Cuts in funding has meant that the government has delayed the introduction of its flagship cap on the amount families would need to pay for social care because local authority finances are too fragile to cope. 

In 2011 the Dilnot Commission called for a cap of £23,000 on the costs to be born by an individual. This would have meant that when the care costs had reached that threshold then state funding would kick in. Next year the Government was to set a cap of £72,000 - three times the level recommended by Dilnot. But even this has now been delayed until 2020.

Local authority funding is varied across the country, leaving a post code lottery for public funding of social care and hundreds of thousands are missing out on support for care costs. The root cause of the problem is cuts in government funding to local authorities. Age UK estimates there are more than one million left struggling each day without proper support and the numbers continue to grow as cuts in funding leave local authorities struggling to meet needs. 

A report published by adult social care chiefs (Association of Directors of Adult Social Service (ADASS) earlier this year warned of £1.1bn budget cuts to the sector. Additional funds, it said, are urgently needed to protect services after "almost unendurable" cutbacks in the past five years. Spending on the NHS has remained static at best, whilst funding for social care has been cut by 10.7%. It is a false economy. 

Most of the care is being provided by some 6 million unpaid carers - partners, parents, siblings. The burdens of such care mean that many of these are unable to stay in work and it may also lead in turn to health issues. The cost to the economy of people dropping out of work to care is estimated to be a massive £1.3 billion a year through foregone taxes and benefits for carers.

With the growing need for social care you would think that private social care providers were thriving businesses.  Yet this is not so.

Britain's care homes are facing a financial crisis with a recent Care Quality Commission (CQC) report warning that high debts, diminishing local authority fees and rising costs could lead to "another Southern Cross style crisis".  

Private sector care came under scrutiny in 2011 when Southern Cross, a 750-home operator, collapsed  under a mountain of debt and controversy over its business model. It was controlled by private equity firm Blackstone, which sold off and then leased back its 750 care homes.  With increased rents, falling local authority income, and rising operating costs it collapsed with an unsustainable debt burden. Thousands of vulnerable residents were left in limbo as the group was broken up and its homes sold off to rival operators.

Bupa reported a £1.2m loss in its UK care home business last year with speculation of a mass sell off of its care homes, whilst  there is also speculation that Care UK, one of Britain's biggest care providers is about to sell off all its domiciliary care services. 

The UK’s largest care home provider is considering selling scores of its properties as it plans to trim its budget. Four Seasons Health Care has seen a 5% reduction in fees over the last five years. The company, which cares for thousands of residents, faces a £500m deficit in its finances after government spending cuts. 
When the banks failed the government stepped in to rescue them.  Now social care is failing as a direct effect of government cuts.  It is time the government stepped in.  It is time for a new strategy.  Austerity isn't working.  It is time for an integrated approach to health and social care.  It is time they accepted that social provision is necessary. It is time to end the belief that markets and price settle everything. It is time the government stopped ideologically destroying the social fabric of Britain with their systematic attack on the welfare state. 

Good government should have both social and economic objectives. Instead the government foolishly sets an objective to cut the deficit. Its solution is always to sell, sell, sell, rather than build and create. It attacks the poorest whilst giving tax breaks to the rich.  The market in social care is failing. Time for social provision. 

Saturday, 14 November 2015

Who pays for the damage of 'free' global markets?

Some of my recent blogs have been about markets. This is no exception. The point I make is that the neoliberal view of 'free markets' meeting needs is a myth.  Markets are neither 'free' and nor do they meet social needs or environmental health - the neoliberal view has no need for  'social need'. It speculates on the future without heeding the consequence. It simply considers social need as aggregate individual need.

But as I pointed out in my previous articles, social need is more than the sum of aggregate individual need, and the problem with the 'free' market is that it has no 'social conscience' - there is no market measure or price for social need.  The neoliberal wants a 'reduced State' which means substantially reduced public spending.  Many are appalled at poverty levels increasing, yet there is no market for 'ending poverty'.  Growth without social provision won't meet social need. But let's take another example - the environment.

There is an urgent need to end and reverse deforestation - I know it, you know it - but in what market can we effectively express that demand? Certainly not though price of goods, because as demand for goods increases, so does deforestation.  Did you really want that when you bought your last packet of corn flakes?

As the human population continues to grow, so does the need for more food. Rising demand has created incentives to convert forests to farm and pasture land to grow food and for biofuels.

Once a forest is lost to agriculture, it is usually gone forever—along with many of the plants and animals that once lived there. It is the major threat to bio-diversity.  Did you want that the last time you bought a bar of chocolate?




It is estimated that 15% of all greenhouse gas emissions are the result of deforestation. Yet, some 46-58 thousand square miles of forest are lost each year—equivalent to 36 football fields every minute. 17% of the Amazon rain forest has been lost in the last 50 years, mostly due to forest conversion for cattle ranching. Did you want that when you bought a can of corned beef? Deforestation is happening as I write this piece, and it will continue while you read it.



Here in the UK 85% of domestic demand for wood products is met from imports, amounting to a value of around £6 billion annually.  Sweden, Latvia, Finland, Russia and Estonia together account for nearly 90% of all UK sawn softwood imports.  We need to build more housing and this will require more wood unless other materials are used. We know that whatever we do there is an environmental impact both locally and globally.  In terms of our environmental impact we are not an island. Our choices have impact on others across the globe and on future generations. Big global corporations trade with little accountability for their impact on local environments or the social consequences of their actions. 

The cost of pollution is real, but it is rarely factored into ‘production costs’. The cost of polluting now is met by future generations or by the public in clearing up the mess, or adjusting to the consequences of climate change. Those who produce greenhouse gas emissions are therefore imposing potentially huge costs on other people over time, yet our tax system doesn't reflect this.

There are essentially two ways in which ‘carbon pollution’ can be factored into costs: straight carbon tax or creating what is now called a carbon price.  But there are social costs too, such as impact on communities that are difficult to reflect in price.  They require action from government and regulation to prevent. 

The Committee on Climate Change estimates that a carbon price of £30 per tonne of carbon dioxide in 2020 and £70 in 2030 would be required to meet the goal of reducing emissions by 80% in 2050. Currently, many large UK companies pay a price for the carbon they emit through the EU's emissions trading scheme. However, the price of carbon through the scheme is considered by many economists to be too low to meet  targets. 

The EU emissions trading system  is a cornerstone of the European Union's policy to combat climate change and its key tool for reducing industrial greenhouse gas emissions 'cost-effectively'. The first - and still by far the biggest - international system for trading greenhouse gas emission allowances, the EU ETS covers more than 11,000 power stations and industrial plants in 31 countries, as well as airlines.

It is estimated that by 2020, emissions from sectors covered by the EU ETS will be 21% lower than in 2005. By 2030, the Commission proposes, they would be 43% lower.  In October 2013 the International Civil Aviation Organization (ICAO) Assembly agreed to develop a global market-based mechanism to address international aviation emissions by 2016, and to apply it by 2020. But many environmentalists believe this is insufficient to have impact on the growing environmental challenge.

Effectively producers are buying their pollution at too low a price and with little incentive for increased efficiency to reduce it. 

In the UK the Chancellor of the Exchequer announced in the Summer Budget this year that the Climate Change Levy is being extended to apply to renewable power, effectively turning it into an energy levy. This suggests a major shift to an attempt at reducing greenhouse gas emissions by simply trying to decrease energy demand by raising taxes on consumption,  and without further policies to encourage a shift to low-carbon production.  The cost will be payed by the consumer with no incentive for the energy producer to produce cleaner fuel. 

Meanwhile, the carbon price for emissions in the UK is likely to remain below that compatible with the objective of reducing greenhouse gas emissions cost-effectively. 

The price of fossil fuels does not reflect their true costs, including the 'externalities' they create because greenhouse gases and other air pollutants damage health  through climate change, increased risk of heart disease, asthma and other diseases resulting from such pollution.  The price of food doesn't reflect the  true costs  of damage to the environment such as deforestation and its impact on global warming and bio-diversity. The biggest lobbyists against regulation are big businesses. Meanwhile, stock markets speculate on future price whilst failing to consider future consequences.  We are not paying the true price, but future generations will.

Human beings are a social species. We have the ability to create our environment just as we have the ability to destroy it.  We are a unique species in that we have an extended cultural history and can consider the consequences of our actions into the future.  We have choices we can only make effectively as a community, as a society, as an economy. It needs political will, not simply 'free' markets.