Sunday, 29 March 2015

The Tory ideological attack on the poorest

The majority of people on benefits in the UK are hard working and on low pay.  Many of them would be on the kind of zero hours contracts that the Prime Minister conceded, eventually,  in his interview with Jeremy Paxman that he would not like to be on.  He was also asked by Jeremy Paxman where the cuts would fall to deal with the deficit.  The answer of course is 'cutting benefits' and through further 'efficiency savings'.   It is all pie in the sky.  Either the Prime Minister has no idea how they would cut the deficit or the Tories have a hidden agenda.  Actually, it is not so hidden. They will cut 'welfare'.  That is what would happen - swingeing cuts in welfare.

Swingeing cuts in welfare will hurt the hard working poor.  The poorest are already paying disproportionately more tax than the wealthiest.  They have already suffered through measures such as the 'bedroom tax' and other cuts in benefit.

At the outset of the coalition five years ago, we were told we were 'all in this together'.  But it has been the poorest who have suffered the most because of the greed of the bankers. It was the banks who brought havoc and ruin to the global economy.  Now the poor are made to suffer.

It is no real secret that the Tories are planning further attacks on benefits.  They do so not simply to cut the deficit but through ideology.  But what really gives the lie to their claim to cut the deficit is tat at the same time as they plan this further assault on the poor, they are cutting taxes and providing further benefits for those who can afford to save.

This government slashed funding to local authorities by 40% which in turn meant a cut of 20% in funding for social care.  This is a major factor in the increased load on the NHS.  The Prime Minister now peddles reconditioned policy initiatives such as providing a 'seven day a week' NHS.  Most of my neighbours already thought the NHS was supposed to be 24/7.  Now they learn that it is not, but the Prime Minister will sweep down form high with new funds to make it so.  But they are not new funds. The NHS will have a funding gap of £30 bn by 2020.  It has already had £20 bn cuts in 'efficiency savings' and yet in his interview with Mr Paxman the Prime Minister believes it can find a further £30 bn over the next five years.  It doesn't add up.  It doesn't make sense.  It is, as the BMA, rightly point out 'playing games' with the NHS.


Saturday, 28 March 2015

Worthless promises on the NHS

Mr Cameron's shameless 'promise' to provide a 'seven-day a week' NHS has rightly been condemned by the BMA, the doctor's association.  What Mr Cameron needs to demonstrate his how he would fill the £30 bn gap in funding that will develop by 2020.  Unless any of the political parties can explain that then their promises are empty rhetoric.

The coalition government has effectively cut funding for the NHS at a time when demand on its services is increasing.  Mr Cameron was quick to boast in his interview with Jeremy Paxman this week that spending on the NHS has increased.  What he failed to say was that it was by just 0.9% per year, the lowest levels on record.  With 40% cuts in local authority funding leading to 20% cuts in social care the burden on the NHS has increased.  This is a direct result of government policies.  In addition the NHS has had to find £20 bn in 'efficiency savings' at a time of complex 'top down' reorganisation imposed by the government - a government that promised there would be no 'top down' reorganisation.  It broke the promise to 'ring fence' funding; it broke the promise for no 'top down' reorganisation, with the result that the NHS is on the brink of crisis.

So what does the Tory party offer? They say that the £30 bn will be found through 'efficiency savings'.  It has got to the point where there is little left of a credible strategy for the NHS.  It is head- in-the-sand time and the promises offered are worthless unless they can be backed by a credible financial plan.

The crisis in the NHS is of the government's making. Their twists and turns and promises are shameless.

We need to hear credible policies on the NHS from the leaders of the main political parties. Until they provide them, their promises are worthless.

Friday, 27 March 2015

Playing games with the NHS?

The Labour Leader did a decent job of his interview with Jeremy Paxman last night. My judgement is that he 'won' the debate that wasn't held - instead we had the two main party leaders facing separately Jeremy Paxman and the studio audience.  There was no head-to-head confrontation.  But in my view Ed Miliband 'won' because he didn't 'lose'; in contrast, David Cameron 'lost' because he didn't 'win'.

What really came out of it was Ed Miliband in a different light - not the 'geek' he has been portrayed, but a forceful and motivated leader.  This came out in his answer to the question of why he stood against his brother, David, for the leadership.  He gave a good account of himself.  But, and it is a big but, there was nothing from either of the two leaders about how they would deal with the £30 bn gaping hole in funding that will develop in the NHS over the next 5 years.

The NHS is uppermost in the issues of concern to voters.  Yet neither party has produced convincing answers to the principle question of funding.

Responding to a speech by Ed Miliband marking the launch of the Labour Party General Election campaign today, in which he outlined Labour plans for the NHS,  the BMA (the doctors representative association) called once again for the parties not to play games with the NHS.

Dr Mark Porter, BMA council chair said:

“The test of any health policy should be whether it benefits patients, yet 95 per cent of doctors do not believe the quality of patient care has improved under the Health and Social Care Act 2012.

“Proposals to remove the most damaging elements of the Health and Social Care Act 2012, to support more joined up care and to prevent the private sector from cherrying picking the most profitable services are a step in the right direction. The BMA wants a publicly provided and funded health service, and believes the NHS should always be the preferred provider."

He called for a commitment to provide more GPs to meed growing demand.

"A commitment of more GPs is vital to meet rising demand on services, especially as more care is being delivered in the community. However, with general practice facing a recruitment and retention crisis we must first address the challenge of getting more doctors to choose to become GPs."

The Prime Minister, David Cameron insisted in his interview with Jeremy Paxman that funding for the NHS had risen over the last five years. Yes it has,  but by the lowest ever level or just 0.9% per year - not enough to meet the growing demands for care in the community and pressures on A&E.

The government have cut local authority funding by 40% which in turn has reduced funding of social care by 20%. The consequence is an increase strain on the NHS.

Commenting on Ed Miliband's speech opening the Labour campaign and promising more funding for the NHS',  Dr Mark Porter says:

“While extra funding is desperately needed, this announcement falls far short of explaining how the NHS will plug the £30bn gap it faces by 2020."

The NHS faces a crisis in the coming years. Sticking plaster solutions won't do.

“There must be no more games with the NHS. Rather than political parties bidding against each other for sticking plaster solutions which don’t go far enough, what is needed is a serious, detailed look at the investment health and social care services will need to cope with rising demand from an ageing population, and a long-term, fully funded plan to deliver this. This is the only way to ensure the NHS can rise to the enormous challenges facing it.”

Thursday, 26 March 2015

Government fail to make economic case for HS2

Is HS2 (the proposed High Speed Rail link between London and the North) value for money?  A new report by the House of Lords Economic Affairs Select Committee says not - or at least that the government has failed to make a sound economic case.

The construction of the railway and purchase of rolling stock is estimated to cost up to £50 billion. The net cost to the taxpayer is expected to be £31.5 billion at 2011 prices over 60 years.  This is a costly project.  You would think then that a sound case had been made.  But the committee concludes that such a case has not been made.

The Government's principal justification for building HS2 is to provide capacity to meet long-term rail demand.  But the committee finds that  inadequate information on rail usage and demand modelling makes it difficult to determine whether this is correct. Overcrowding appears to be caused by commuter traffic, not long-distance traffic, and is exacerbated by inflexible pricing.

The main charge of the committee is that alternatives have not been considered, and the committee concludes it is impossible to agree with the Government that HS2 is the only solution to increase capacity on the rail network. Furthermore it argues that additional capacity could be provided by incremental improvements to the existing network, a new conventional railway line, or a new high-speed line (of which HS2 is only one option).

"These options have not been assessed equally, with only HS2 receiving serious consideration by the Government" is the damning conclusion of the committee.  It is even more abrasive when it considers the impact on the economy.

"We do not believe that the Government has shown that HS2 is the best way of stimulating growth in the country. While investment outside London is long overdue, evidence and experience from other countries has suggested that London would be the biggest beneficiary of a project such as HS2."

 The government has failed to listen to the concerns about the environmental impact and pushed on with the project without having made an assessment of the likely damage.  The did so arguing that the economic case for HS2 was overwhelming.  It isn't.






King's Fund indictment on NHS and social care funding.

The King's Fund has produced a devastating analysis of the impact of the coalition government's austerity measures on the NHS and on Social Care.  Cuts in local government funding of some 40% have led to a 20% cut in funding of social care provision.  This in turn has led to an increased load on the NHS at a time when funding has been restricted and it has had to find £20 billion in 'efficiency savings'.  The real terms increase in spending on the NHS over the last five years is the lowest it has ever been at 0.9% per year.  The result is an NHS in crisis with patient care under risk.

it estimated that a funding gap of £30 billion will develop over the next five years.

Today the BMA, the doctor's representative body has issued its response to the King's Fund report.

 Dr Mark Porter, BMA council chair said:

“This report highlights the damage done to the NHS by the Health and Social Care 2012, which distracted attention from rising pressure on services and cost billions to introduce.

“Staff have done as much as they can to protect and improve patient care but, as this report lays bare, after years of underfunding the cracks are beginning to show. Patients face longer waits for treatment, services are stretched close to breaking point and staff are under unsustainable pressure.

“The NHS is the best health care system in the world, and the most efficient - there is no fat left to cut without patient care being hit. The report makes clear that further cuts to front-line staff pay are not a solution to the funding crisis in the NHS. Instead they leave staff feeling demoralised and devalued at a time when they’re working harder than ever to deliver for patients.

“With an election weeks away, politicians of all parties must stop using the NHS as a political football. Rather than short-term political game playing, the NHS needs a long-term, fully funded plan to protect patient care, support front-line staff and ensure it can rise to the enormous challenges facing it.”

Just five years ago the coalition promised to 'ring-fence' the NHS from the measures to cut the deficit.  This it has signally reneged on.  David Cameron promised there would be no 'too down' reorganisation of the NHS.  This he has reneged on.  At a time when it has faced severe financial pressure the government embarked on an extensive reorganisation of the commissioning process, which it did without proper consultation.

The King's Fund report is a shocking indictment of the coalition's approach to the NHS and social care.

Tuesday, 24 March 2015

Coalition cuts hit social care for the elderly

In the run up to the general election I am wary of many statements I hear abut the NHS and social care.  One general statement is that 'it isn't all a question of money'.  This is true - of course it isn't all about funding.  But what are we to take from such a statement. It is usually made when people complain about the level of funding.  It is a 'catch all' reply.  It is also somewhat disingenuous as a reply because it is meant to avoid the real issue, funding.  We now spend 17% less on social care than we did I've years ago.  This is not surprising because  social care is mostly funded through local government, which has seen its financial support from central government cut by over 40 per cent in real terms since 2010.  Yes, 40%!  That is the nature of what we have been doing over the last 5 years to 'cut the deficit'.  

In his budget last week Mr Osborne cut taxes on beer and spirits to try to generate a 'feel good' factor for the general election. It was a cynical ploy.  His 'cuts' in taxes leave a £10 billion black hole in funding for public services.  If he was serious about cutting the deficit then he wouldn't cut his tax revenue. 

We have been in a strange state of hear no evil, see no evil in relation to 'the deficit'.  One of the successes we might have been proud of in the decade running up to 2010 is that pensioner poverty had bee substantial reduced.  Now that has been reversed with spending on the elderly cut by 17% in real terms over the last five years.  

Overall spending on adult social care services was £14.6 billion last year with  46 per cent of that  spent on people over 65. From April this year the Better Care Fund will transfer £3.8 billion from the NHS budget to support spending on social care.   This should also  benefit the NHS  by reducing pressure on hospitals.  But let's face the facts of this. It is arranging the deck chairs and not necessarily fixing the problem.  

The NHS has endured cuts of some £20 billion in 'efficiency savings'.   This is another euphemism I am wary of.  There is an idea that we can cut funding in ways that does not affect 'front line' services. It is as if the 'front line' was not dependent for function on the back staff, when of course it is.  We hear often of the admin work that front line staff have to do.  

Another statement I am wary of is 'we are spending more on the NHS'.  Again it is true, but it is disengenous. Spending on the NHS has gone up in real terms during the last five years by and average of 0.9 % per year.  This is the lowest average annual change of any parliament.  It  contrasts with average annual increases of 5.7 per cent under the Labour administrations between 1997 and 2010 and 3.2 per cent under the Conservative administration between 1979 and 1997.  Even Thatcher outspent this coalition government on the NHS!

Yet with massive cuts in funding for social care the burden has increasingly fallen on the NHS.  The result: an NHS crisis. 

So as we rejoice over a pint of beer let's think of the cost of that penny cut in tax. 

Saturday, 21 March 2015

Anonymity for suspects is justice

The way Sir Cliff Richard has been treated by the police and the BBC in relation to allegations of sexual misconduct is a disservice to justice.  The deliberate leaking and collusion with the media to provide maximum publicity is a shocking breach of trust.  Allegations of sexual abuse must be pursued where there are sufficient grounds for doing so,  but deliberately making known the identity of a suspect is to put justice at risk for both potential accused and victims.  It sets up a 'trial by media' where those accused have no rights to defend themselves or facility for rebutting allegations. It creates a 'no smoke without fire' concept and tarnishes reputations.

It has become a particular problem with the investigation of historic cases following the Jimmy Savile revelations. Almost anyone in the public eye has become 'fair game' for the police and the media without a thought of the normal process of justice.   The police on the one hand want to widen their investigation and want possible victims to come forward.  But how they approach this must be balanced with protecting the rights that people have not to be left with allegations in the media but without prosecutions.

The question of the anonymity of the accused is once again the subject of public debate.  The number of well-known people arrested as part of Operation Yewtree and other, related investigations has brought the issue into the spotlight and social media has amplified the 'repetitional damage' that can be inflicted by naming a suspect.

Now the Home Affairs Select Committee of the house of commons has called for anonymity for suspects until such time as there is sufficient evidence to bring charges. Suspects, they say, should have the same right to anonymity as that given to victims. If police need to release information about a suspect as part of an investigation then this should be through a formal process. Furthermore there should be a zero tolerance to any leaking of information by the police to the press and media.

As the Home Affairs Committee point out in their report, being arrested and held on bail is no indication of guilt. It means simply that the police have acted upon a reasonable suspicion, carried out an arrest, and wish to continue to investigate the allegation without holding the suspect in custody. This is a much lower bar than that required in a court to establish guilt, and in fact a much weaker test than the Crown Prosecution Service applies when deciding whether or not to prosecute, which requires that there is sufficient evidence to provide a realistic prospect of conviction.  Yet reputations can be tarnished.  In some notable cases there has been leaks of names to the media even where charges have not been brought and arrests have not been made.

The Sexual Offences (Amendment) Act 1976 initially introduced anonymity for complainants, initially only in rape cases, but subsequently extended to other sex offences, but the provisions granting anonymity to the accused were repealed in the Criminal Justice Act 1988, and accused persons currently have no entitlement to anonymity.  During its inquiry into the Sexual Offences Bill 2003, the Home Affairs Committee called for anonymity for the defendant in such cases, because it felt sexual offences were “within an entirely different order” to most other crimes, carrying a particular and very damaging stigma.

Trial by social media is no substitute for the rigours of a proper investigation and trial by a court.







Thursday, 19 March 2015

Chancellor cut the price of beer whilst the NHS is in crisis.

I suppose I should comment on the budget. It is to say the least a curious budget for a Chancellor who has spent five years telling us we must cut the deficit. He now tells us that he has £6 billion to spare. Fantastic! Or should I say 'hey we have an election'.  So what has he chosen to? He cut duty on beer. Now that is really what we needed.  It is the little things that say a lot about this government's priorities.  Was this a budget for the poorest? No.  Was it a budget to help the NHS or to help pay for social care? No.  it was an election budget.

 The NHS is facing a crisis and the Chancellor prioritises the price of beer.  It is a very odd priority. He chose to do very little that would help the poorest.  This point was made by a woman interviewed in the street on BBC news.  It is all very well helping people save, she said, but it only helps those who have money to save.  And there you have it. It is a budget directed at those in marginal constituencies whose vote might make a difference in he general election.

What we know is that if the Tory party wins that election we are in for a continued period of cuts. The Tories are bent on doing what they think they have failed to do in the coalition: 'roll back the state'.  The Conservatives came into office saying they would protect the NHS, make people better off and balance the books, yet given the opportunity he cuts the price of beer.

Th tax and benefit changes since 2010 have left families on average £1,127 a year worse off. Yet, his priority is the price of beer.  The Chancellor now says he wants to go far beyond balancing the books: he has a target of a £23 billion budget surplus in 2019/20 and £10 billion of unfunded tax promises. And yet, the NHS is in a funding crisis.

It is no secret that the Tories are now planning even deeper spending cuts in the next four years than during the past five.  This will hit the poorest the most.  Those who have already been hit by five years of austerity.  Now we are told that the pain must continue to 'balance the books', and yet he gives away £10 billion in unfunded tax promises.



Sunday, 15 March 2015

Call for free social care for those at the 'end of life'.

Each year around 500,000 people die in England and Wales. In 2013, approximately 80% of those who died were people aged over 65. One third of all deaths are people aged 85 and over, but only 15% of those who receive specialist palliative care are in this age group.

In a report published today, the Health Select Committee of the House of Commons recommends that social care should be free in end of life situations.

The report looks at the state of end of life care since the independent Review of the Liverpool Care Pathway, chaired by Baroness Neuberger,  and finds great variation in quality and practice across both acute and community settings.  They call for round-the-clock access to specialist palliative care in acute community settings saying this "would greatly improve the way that people with life-limiting conditions and their families and carers are treated, especially if there were opportunities to share their expertise with other clinicians."

This is a key ingredient of proving effective, person centred care with dignity and understanding. Those cared for come with individual histories and wishes.  The care must be centred on the person and the expertise of all the involved  should be more equitably available to people with a non-cancer diagnosis, older people and those with dementia, for whom early identification and sensitive discussion and documentation of their wishes is also important.

The question of when and how it is determined that a person is in an 'end of life' situation  and how best this can be discussed is difficulty. The reports calls for all staff providing palliative and end of life care to people with life limiting conditions to receive training in advance care planning, including the different models and forms that are available and their legal status.

They make the point that most people who express a preference, would like to die at home but that is also made more difficult by the shortfall in community nurses and specialist outreach palliative care.

The large majority of deaths follow a period of chronic illness such as heart disease, cancer, stroke, chronic respiratory disease, neurological disease or dementia. Most deaths (53%) occur in NHS hospitals, with around 21% occurring at home, 18% in care homes, 5% in hospices and 3% elsewhere.  This is despite the fact that 63% of people say that they would prefer to die at home, while 29% would prefer to die in a hospice.

Hospital was found to be the least preferred place of death in a study carried out by the Cicely Saunders Institute. Other sources put the figure for home as the preferred place of death even higher: ComRes polling for the Dying Matters Coalition in April 2014 showed that 72% of people would want to die at home. Macmillan Cancer Support cite evidence that shows that 85% of people who die in hospital would have preferred to die in another setting.  People do change their minds however and the stated preferred place of death may change as death approaches.

Social care should be more flexible and coordinated to meet patients wishes as best as possible.

The key recommendation is that free social care at the end of life should be provided to ensure that no one dies in hospital for want of a social care support in the best environment that meets the wishes of the person whose life is coming to an end.








Friday, 13 March 2015

Mr Farage knows what voters will think he means

It is a good trick that Mr Farage plays on behalf of UKIP.  He says something controversial such as answering No to the question whether there should be any race discrimination laws.  He then gets the startled reaction he knows it will get. He then says this has been misinterpreted.  The media say he has 'backtracked'.  But the message has hit home as it was intended.  He has successfully played the 'race card'.  It appears both bumbling and 'telling it like it is' at the same time. It is appealing to those who feel that the truth about immigration isn't being debated.  But it is a trick - a deft slight of hand.

It brings Mr Cameron out to condemn it, which Mr Farage is grateful for - after all 'we are not racist' are we. it is just that....'  Mr Cameron confirms he and the Tory party doesn't speak for those who have turned to UKIP.  Mr Miliband comes out and condemns it giving even more fuel to the fire of publicity.  The trick is working wonders.  Mr Farage comes out and says it is all a 'storm in a tea cup'.  He never said that?  Probably not but for those who like storms in tea cups it does wonders.  Mr Farage upstages everyone and steals the agenda for another few days.  The trick works.

But what on earth can the other party leaders do about it? Now that is the question.  They can't win because there is always some nuance that allows Mr Farage to say he 'didn't say it' and it has been 'misconstrued', 'misunderstood', 'taken out of context'.  I wasn't talking 'race' I was talking 'nationality'.  Ah, that makes all the difference.

Mr Farage is right about one thing and that is that we haven't really been able to have a real debate about immigration because of the association with the race issue.  There are however issues to be discussed. This the public knows.  This the public feels and ordinary voters out there (where? Over there!) believe it should be 'dealt with'.  This is why Mr Cameron said he would 'deal with it'. He set targets that frankly were always unlikely to be attained without some sort of luck or divine intervention.  You cannot stop migration in the EU. The free movement of people is one of the key pillars of the EU. Nor would we really like it if it wasn't.  There may be more people who now come to the UK from other parts of the EU,  but so many UK citizens have gone to other parts of the EU either to retire or to work.  It does work both ways. Now our economy is going better than many other parts of the EU and it is inevitable that there will be an attraction to come to work here. Over time the pattern of migration changes.  Even Mrs Thatcher supported the free movement of people. She extolled the free market principle; the free movement of capital and labour.

The Tories got themselves in a mess over the issue of immigration.  Nigel Farage is perfectly entitled to exploit it.  Yes, he has now played the 'race card, but Mr Cameron created the background for him to do so. That is a problem., and the trouble is that once the genie is out of the bottle (sorry for the mixed metaphor), then it is difficult to put back again.  Mr Cameron has a habit of doing this - letting genius out of bottles that is. He did the same over  Scotland independence.  He first called Mr Salmond's bluff on a referendum and then started to play party politics with the result. He continues to do so, challenging Mr Miliband over the prospect of a coalition with the SNP. It is saying to the Scottish people that they won't have a say in who forms the next government. That from the point of view of keeping the union together is a very silly card to play.

I would suggest Mr Cameron stops playing politics with issues.  What? Politics? But isn't he a politicians? Isn't that what politicians are supposed to do? Yes, I suppose it is.  It is a dangerous game.

Wednesday, 11 March 2015

The election and cutting the deficit

What is it all about and does it matter? The general election that is. It is often remarked about the main political parties that 'they're all the same'. It is certainly true that increasingly they have come to sound the same.  This is in large part, not because the policies are the same, but the pitching of them is similar: the same target audiences, the same cliched lines, the same sort of sound bite. It is also the case that policy differences are often nuanced rather than substantial. But the differences are none the less real. The impact of these differences is not so much through individual policies but through overall strategy.  We here the same soundbite about 'cutting' the deficit, 'dealing' with the deficit from all main parties. We 'must' cut the deficit has become a mantra, almost unquestioned -  a kind of political truism.  But is it really the case that we must? And do all the parties really agree? What's the real alternative in the general election? A better understanding comes from a consideration of the deficit.

We need to look at the deficit and the Total Managed Expenditure across a cycle.  It is clearly the case that holding TME constant it will fluctuate as a % national income.  During  a boom when growth in national income is high then spending will fall as % of that income; during a recession or period of slow growth then TME will increase as % of national income.  Given that we wish to increase spending on capital investment, in infrastructure or house building that helps the economy to prevent a recession, then again we should expect TME to rise as a percentage of national income.  During a recession, with increased unemployment, the welfare bill increases., increasing expenditure..

All this is why cutting the deficit should be seen across an economic cycle.  Simply setting targets for spending cuts without considering the consequences would do more harm than good.  We need a balanced view to cutting ‘the deficit’.

The Tories it seems are, if their coalition partners are to be believed, itching to cut the deficit by slashing spending.  It has become no longer a question of economics, but a question of political philosophy. – rolling back the state. Come what may, the Tories have an instinctive dislike of public spending.  The good that it does is, for them, outweighed by the harm they consider it does.  Not for them the ‘nanny state’ and ‘welfare dependency’.  Labour on the other hand instinctively believe in public spending, not as an economic principle so much as a social principle.  They believe that the good that it can do outweighs the potential harm of ‘dependency’.  The Tories ‘dependency’ is Labour’s ‘support’.   Labour in more recent times has been more in the centre ground of that divide.  If Labour is moving to the left of New Labour it is because the centre of gravity in that divide is shifting.  Experience teaches a lot, and the experience of the last five years has pushed many Labour supporters to reassert their belief in the role of public spending.

This political emphasis is reflected over the long term – although not necessarily in the short term where events blow governments off course..  The average real rate of increase in spending during the Conservative years of 1979 to 1997 was 1.5 per cent, and under the Labour government from April 1997 to March 2009 it has been 3.2 per cent.   It reflects the tendency for Labour to seek social solutions to what it considers to be social problems.  The Tories on the whole seek ‘market’ solutions to what they consider to be distortions of economic reality. – profit driven efficiency with somehow lead to the solving of deprivation in a trickle down – greater wealth creation by free spirited entrepreneurs leads to more jobs and everyone benefits.  To some extent New Labour blurred this divide – it recognised to a greater extent the role of market forces.  Since the banking crisis Labour has taken renewed stock of its position and has begun once again to think ‘social’, if not socialist.

All this means that the lines of the coming general election are more clearly drawn than appears at first glance.  Much more is at stake as a result.  A Tory government will as a matter of political belief cut spending.  Labour will make sounds about cutting the deficit but will resist massive cuts in spending.

The Liberal Democrats adopt a positon that holds something like  ‘we will prevent the Tories an excessive rightward shift an we will prevent Labour from a lurch to the left’.  Frnakly I suspect the voters are fed up with such a balancing act.  The LibDems are likely to be punished at the election.  But they won’t be punished as much as some polls suggest.

I expect we will hear much more about dealing with the deficit in the election - each party trying to outbid the other.  The Tories will say that Labour will spend more and won't cut the deficit. Labour will say that the Tories will slash spending.  The choice is real.  They are not all the same.

Nuffield Trust issues stark warning on A&E

With the general election fast approaching the NHS remains at the top of the list of issues of most concern to voters. Now a new policy briefing by the Nuffield Trust has warned that continued financial squeeze on the NHS will accelerate the pace at which the urgent care system reaches breaking point. The report concludes that the most significant issue is not the numbers of people presenting at A&E, but the ability to discharge patients safely and quickly from the hospital
as a whole. That is, it is not A&E as such where the problems lie. A&E is part of an integrated system  and the four-hour target for waiting can distort behaviours inside hospitals and health systems in ways that are not in the interests of patients or staff.

Understanding the real problems through the chain is vital to resolving any issues and they make the key point that

 "the complexity of the system and the highly politicised nature of A&E have impeded progress. Problems will not be solved if policy-makers, political leaders and regulators continue to micro-manage A&E. With changeso urgently needed, it is imperative that there is a cross-party consensus on how to move forward and that action is not postponed or delayed for political reasons."

The report chimes well with the BMA campaign calling for an end to 'political games' with the NHS. The authors point out that problems in A&E are complex and difficult to solve and many of the solutions proposed are 'overly simplistic'.

They make the point that the 4 hour waiting  target has played an important part in improving patients’ experiences of care at A&E. Before the target was introduced, 12-hour waits were
not uncommon. The improved performance was maintained for the best part of a decade.  But performance has slipped since 2012,  and the target has not been met since the summer of 2013.

This increased pressure on A&E is demonstrated by some key fact. There has been a sizeable increase in the number of A&E attendances, from 16.5 million in 2003/04 to 21.8 million in 2013/14; a rise of 32 per cent,  was almost exclusively to do with minor A&Es (for example, urgent care centres, minor injuries units and walk-in centres).

The report puts forward several proposals to deal with the problems.

Focus on getting things right in primary care to enable prevention to work – but be realistic about how much can be achieved. Policy-makers can help to boost primary care through supporting moves to build up the skills and capacity of health care professionals to provide high-quality urgent care services outside hospital.

Remove some of the complexity of different services that has been built into the system, and which confuses the public and NHS staff. Creating a single point of access to community services for patients and GPs would be one way to achieve this.

Focus on the way patients move through hospital – and be realistic about what policy-makers can and can’t do. Policy-makers can help by investing in care outside hospital, but they must let providers find solutions that work for their patients.

Foster a better understanding of the way that local systems work.
Promoting better data outside hospital and encouraging the development of systems modelling in individual trusts would be an important start.

Take a longer-term and broader view of performance in A&E – and consider clustered randomised controlled trials of alternative performance measures. Policy-makers should encourage the adoption of a set of richer performance indicators to sit alongside the four-hour target, which could be trialled in certain areas.

The report concludes with a clear warning that our urgent care system is 'near breaking point'. The continued squeeze on resources will accelerate the pace at which it reaches that point. 'Sticking-plaster solutions will not solve the problem'.


Saturday, 7 March 2015

Not smart on smart meters

Why is it that when it comes to IT we seem to get things so badly wrong? Whether it is in the border agency or in the NHS we seem unable to get things to work or to roll out as planned.  Now we have a problem it seems with rolling out smart meters to save energy, one of the key planks of government strategy on tackling carbon emissions and climate change.  Now a parliamentary committee has warned that plans for installing these meters are in danger.

Plans to install the energy saving smart meters in every UK home and business by 2020 are in danger of veering off-track and could prove to be a costly failure because the project has not been driven forward effectively, the Energy and Climate Change Committee of the House of Commons has warned. In a new report the MPs raise concerns about technical, logistical and public communication issues which have resulted in delays to a national roll-out programme.


Tim Yeo MP, Chair of the Committee, said:

"Time is running out on the Government’s plan to install smart meters in each of the UK’s 30 million homes and businesses by 2020. Smart meters could generate more than £17bn in energy savings for the country yet a series of technical and other issues have resulted in delays to the planned roll-out."

The Committee first looked at the programme in 2013, highlighting issues which they urged the Government to address. As the chair of the committee says, some progress has been made but it is not enough.

"The energy industry told us that it needs the Government to enable industry-wide solutions, rather than the less efficient alternative of letting each energy supplier develop its own solution.

But he also warns that without significant change from government the programme is at risk of failing.

"Without a significant and immediate change to the Government’s present approach which aims to install smart meters in 100% of UK homes and businesses, the programme runs the risk of falling far short of expectations. At worst, it could prove to be a costly failure. So, the Government is at a crossroads on its smart meters policy. It can continue with its current approach and risk embarrassment through public disengagement on a flagship energy policy, or it can grip the reins, and steer the energy industry along a more successful path which brings huge benefits for the country."

Why, oh why is it so difficult?

Wednesday, 4 March 2015

Farage's normality

UKIP leader Nigel Farage has defined 'normality'. Mr Farage told BBC News: "UKIP is putting forward a policy that will take immigration in Britain back to normal. Normal was from 1950 until the year 2000."  Well, that is all well and good then.  I always felt there was something 'normal' growing up in the 1950s.  It had that sense of 'normality' about it. Cars were 'normal', though very rare in the street where I grew up.  Boats, planes and trains were very normal too.  At least they appeared normal. Nothing alien about them as far as I recall.

Of course there was a lot of hocus pocus about the paranormal, but even that was normal.  The 1970s was pretty 'normal' too even though there was a lot of spoon bending going on.  I recall the 'flood' of East Africa Asians - I recall Enoch Powell's 'Rivers of Blood' speech - and all that was 'normal' too. In the 1950s I recall the signs in windows saying 'No Blacks' - and that was normal.  I recall the dockers marching against immigration in the 1960s and that was 'normal'.  I recall a lot of concern about immigrants, and that was 'normal'.

Now it seems Mr Farage wants us to believe that we have been living through something not normal. I guess we have been living in a dream since 2000 and when we wake up to 'normality' it will be let's say 1st January 2001 - the day of abnormality.

Mr Farage is fond of playing with figures. Now he says he doesn't like caps and targets.  Yet, last week, UKIP immigration spokesman Steven Woolfe said: "We would seek to have a cap of 50,000 on those coming here for work, for a period of five years."  I suppose the difference is that UKIP caps are 'normal'.

Mr Farage has a concern about those from former communist countries coming to the UK to work, rest and play.  Why he singles these countries out is beyond comprehension.  I think we get more net migration from Spain! But then that I guess is not normal.  Normality, that is the answer to it all. If only we would get back to it, normality that is.  Back to the future.  It is 'normal' for people from Spain to come here to work, rest and play,  but not people from the former communist states!  I suppose it sounds more sinister if it is former communist countries.  Perhaps they will be undermining our democracy in the interests of a subversive Marxist conspiracy.  Spain of course used to be dictated to by General Franco, but of course that was part of 'normality' as it was between 1950 and 2000.

According to Mr Farage under UKIP, migrant workers would have to have a job paying more than £27,000 a year before being admitted - but there would be exceptions such as nurses.  Of course! Exceptions!  I recall exceptions in the days of 'normality'.  We even advertised for bus drivers. Please come and drive our buses and trains we pleaded in the days of normality, and when they came we called then niggers and made them very unwelcome.  Some stayed and generations later they have made a great contribution to our Britishness.  Thank goodness for normality.

Stop Playing Games with NHS senior doctors warn

As the general election approaches NHS staff are more concerned than ever that they are not being listened to.  As the campaign hots up to get politicians of all parties to stop 'playing games' with the NHS and to put the needs of patients first hundreds of senior hospital doctors from across the UK are gathering in London today for the BMA’s annual consultant conference.

Consultants will discuss key issues affecting the NHS including funding pressures, privatisation, the Health and Social Care Act and the challenges facing the profession from increasing workload, burnout and a recruitment and retention crisis in areas such as emergency medicine.

Speaking ahead of the conference Dr Paul Flynn, BMA consultant committee chair, said:

“Consultants have played a vital role in not just protecting, but improving the quality of patient care in the face of NHS budgets cuts. Many consultants, especially those working in emergency medicine, are working flat-out to keep up with rising patient demand, often in high pressured and challenging environments.

“While workloads are rising, doctors’ pay has been steadily chipped away at in recent years, leaving consultant pay, in real terms, back at 2003 levels. This is because billions of the Government’s so called ‘efficiency savings’ in the NHS have in fact come from cuts to front-line staff pay, leaving doctors feeling devalued and demoralised.

“With only weeks until the General Election, consultants are calling on politicians to stop playing games with the NHS and put patient care first, by listening to the concerns of senior doctors about NHS funding, creeping commercialisation of services and rising workload pressures on staff which lead to burnout.

“Staff are the beating heart of our NHS, which is the best health care system in the world1. It is vital that they feel valued and motivated rather than exploited and overlooked.”

The BMA have warned repeatedly during the last five years of the stress staff in the NHS are working under as 'efficiency cuts' bite into front line services.  You cannot take £20 billion out of the NHS without consequences.  The government promised there would be no reorganisation of the NHS, yet we have had one of the most disruptive organisation in the NHS history.  The government promised that the NHS would be ring-fenced from cuts, yet £20 billion has been taken out of the budget in 'efficiency savings'.  The idea that this would not affect the front-line was always absurd. Now NHS staff are under more pressure.

Consultants are working harder than ever before to keep up with rising demand from an ageing population with more complex medical needs. While demand on services is greater than ever before, investment is falling, leaving staff and services worryingly overstretched. Despite claims that the NHS budget has been protected, the NHS has in fact just undergone its toughest settlement in 50 years and the second toughest in its history.

The effect of rising pressure on services was laid bare in recent BMA surveys in which half of consultants described their workload as unmanageable, and identified excessive workloads as the greatest barrier to delivering the care they wanted to for patients4. Almost half of consultants reported working outside of their regular hours and satisfaction with work life balance had fallen more amongst consultants than any other group of doctors. Many consultants routinely work across seven days, with nine in 10 working evenings and weekends as part of an on call rota with a worrying seven in 10 reporting that they don’t have adequate rest periods between shifts.

Excessive workloads and stressful working environments are leading to burnout and a recruitment and retention crisis in some specialities, such as emergency medicine8, as junior doctors chose to train in other areas of medicine or existing doctors leave the NHS and work abroad.

This provides the backdrop against which more than 18 months of discussions between the BMA and NHS Employers on possible changes to consultant contracts had been taking place9. Talks stalled in October 2014 because the BMA could not accept a Heads of Agreement that didn’t provide adequate contractual protections against excessive workload and burnout, which affect patient safety and care as much as consultants’ health and wellbeing. The Government has since asked the DDRB to consider evidence relating to consultant contracts and make recommendations in the coming months.

Addressing these and other issues in his conference speech today, Dr Paul Flynn, BMA consultant committee chair issued the following warning on consultant contracts:

"Let me make this clear: if the Government wants change, they will have to offer us something in return. Consultants are not superhuman; we deserve time to rest and time with our families. Patients not only understand this, they want it. How many here would like to be treated by an exhausted consultant? Seven out of 10 consultants already report that they don’t get enough rest between duties.

Neither could we commit to accepting the blank cheque that the Department of Health offered, a blank cheque that they would fill in, and probably with a minus number for many consultants.  Despite our many requests for it, no data to support realistic modelling was provided so we could not even have told consultants what they could expect to earn - or to lose - from the proposals. I say to you now, politicians cannot continue to devalue the vital role of consultants in the NHS through a relentless chipping away at pay."

Talking of he pressure on NHS staff, he calls for 'No More Games over the NHS'.

"But this pressure cannot be borne indefinitely and we have seen in some specialties like Emergency Medicine what the consequences of such a strain can be.  Consultants in these specialties know that the problem will not be fixed by one-off injections of funding, funding that politicians often announce several times over. These are the people who crying out for No More Games.  They know that the NHS needs more than empty gestures and posturing in the media. They don’t want the Punch and Judy of politicians bickering for our votes – they know the NHS is far too important for that. For us, the most important thing about this election campaign is not which of the parties will form the next government, but that all of them hear our call for No More Games over the NHS – No More Games with the public’s health, No More Games with NHS funding, No More Games with who provides NHS care."

He also refers to the destabilising effect of the Health and Social Care Act 'diverting money away from frontline care'.

"The NHS is emerging from, but also facing a period of further change. The Health and Social Care Act has had a destabilising effect on patients, doctors and services, diverting money away from frontline care and creating a distraction from what we know are the real challenges facing the NHS: those of rising demand and chronic underfunding. The Five Year Forward View proposes important changes to the model of care, focusing on greater integration of health and social care which will, no doubt, affect how we work. Only last week the Government announced that £6bn of healthcare spending would be devolved to local authorities in Manchester. The challenges posed by these changes are considerable, we must ensure that an already overstretched NHS budget isn’t used to prop up a woefully underfunded social care budget, and we must also ensure that, where appropriate, consultants are put back in the driving seat when it comes to decisions about changes to how care is delivered. We are on the frontline, day in day out, that makes us better placed than any politician or manager to identify how and where improvements can be made in the best interests of patients."

Monday, 2 March 2015

Coffee conundrum — good or bad?

Here we go again — yet another study on coffee consumption and health, this time claiming that moderate coffee consumption lessons the risk of clogged arteries and heart attacks.

I wonder if anyone really takes any notice of such studies.  Just five years ago another study found that people under 55 who drank more than 28 cups of coffee a week were at an increased risk of early death from all causes, with a more than 50 per cent increase in mortality.  So you can take your choice on cup you drink from.

Now, it is claimed  in research published in the online journal Heart people who drink a 'moderate' amount of coffee daily are less likely to develop clogged arteries that could lead to heart attacks.

Researchers from South Korea found that people consuming three to five cups a day had the least risk of coronary calcium in their arteries. Now I wouldn't consider five cups a day as being 'moderate', but I suppose there are some addicted coffee drinkers who take more.  I drink just one cup of coffee in a day,  but often go without.  I drink gallons of tea.  A really good cup of coffee is something to look forward to.

There has been much debate over the effect of coffee consumption on cardiovascular health.

Despite earlier concerns about a potential increase in heart disease risk associated with drinking coffee, a recent meta-analysis of 36 studies showed that moderate coffee consumption was associated with a decreased risk of heart disease. Coffee consumption has been associated with improved insulin sensitivity and reduced risk of type 2 diabetes, but it has also been linked to increased cholesterol concentrations and heightened blood pressure.

In the current study,  an international team of researchers led by the Kangbuk Samsung Hospital, Seoul, in the Republic of Korea, set out to examine the association between coffee consumption and the presence of coronary artery calcium (CAC) which is a early indicator of coronary atherosclerosis – a potentially serious condition where arteries become clogged up by fatty substances known as plaques or atheroma and which can cause the arteries to harden and narrow, leading to blood clots which can trigger a heart attack or a stroke.

They studied a group of 25,138 men and women – average age of 41 – who had no signs of heart disease, attending a health screening examination.

The participants’ screening examination included a validated food frequency questionnaire and a multidetector cardiac CT (computed tomography) for diagnostic imaging to determine levels of coronary artery calcium (CAC) scores.

Annual or biennial health screening examinations are common in Korea, because health examinations are mandatory for all workers under the Industrial Safety and Health Law there and CAC scoring has become a common heart disease screening test.

The researchers estimated the CAC score ratios associated with different levels of coffee consumption compared with no coffee consumption and took potential confounders into account such as education level, physical activity level, smoking status, BMI, alcohol consumption, family history of heart disease and consumption of fruits, vegetables, and red and processed meats.

They categorised coffee consumption as none, less than one cup a day, one to three cups a day, three to five per day and at least five or more per day.

The researchers found the prevalence of detectable CAC was 13.4% amongst the whole group of people and the average consumption of coffee was 1.8 cups per day.

The calcium ratios were 0.77 for people who had less than one cup per day, 0.66 for those having one to three cups every day, 0.59 for those consuming three to five cups per day, and 0.81 for people having at least five cups or more every day compared with non coffee drinkers.

The association was similar in subgroups defined by age, sex, smoking status, alcohol consumption, and status of obesity, diabetes, hypertension, and hypercholesterolaemia.

The association, therefore, was U-shaped, with participants drinking three to five cups per day having the lowest prevalence of arteries that had clogged up.

Possible explanations for the findings, say the researchers, are  that chronic coffee consumption has a possible link to reduced risk of type 2 diabetes, a strong risk factor for atherosclerosis, and that coffee drinking might improve insulin sensitivity and β-cell function.

The authors conclude: “Our study adds to a growing body of evidence suggesting that coffee consumption might be inversely associated with CVD [cardiovascular disease] risk. Further research is warranted to confirm our findings and establish the biological basis of coffee’s potential preventive effects on coronary artery disease.”

So there it is.  Make what you will of it.  I doubt it will have much impact on how much coffee you drink. It will certainly make coffee drinkers feel a bit better.  Indeed they probably do already as another study published in 2013 found that drinking two cups of coffee a day halved the risk of suicide.  On the other hand, although you might be happy you might also get fat because another study published in 2013 showed that regular coffee drinkers were at increased risk of weight gain.

In 2012 a study claimed coffee could protect against bowel cancer.  On balance there are currently more studies demonstrating some kind of benefit of drinking coffee than there are demonstrating adverse consequences.  Is the balance swinging in favour of coffee?

Disingenuous arguments on Europe

It is often said by those who want the UK to leave the EU, or for substantial renegotiation of the terms of Britain's membership, that Britain didn't originally 'sign up to' the free movement of people and an 'ever closer union'.  The free movement of people and thus the problem of migration  is they say a result of the EU and not the EEC which we originally signed up to.  The EEC they claim was purely a common market and not a political union.  It was for the free movement of goods and not people the claim. We had a referendum on our membership of the EEC but not of the EU.  It is to say the least a disingenuous argument because it is wrong.

Certainly what is now referred to  as the Single Market was at the heart of the original Treaty of Rome, which came into force in 1958. That Treaty aimed at creating a “common market”, later “internal market”, covering the whole territory of the then six members of the  EEC.  But what did this market consist of? The common market involved a Customs Union and the free movement of goods – that is, a single external customs tariff plus the abolition of all duties and similar mechanisms between the Member States. But it did more.  It made  provisions for the free movement of workers, of services, and  capital — the free movement of persons was in the Treaty of Rome right from the start  These were  known as the Four Freedoms.  The EEC also made provisions for competition policy and government aid to business. All these mechanisms continue to form the core of the Single Market as we now know it *.

Much of the argument about migration in the EU of course stems now from scale.  The original 6 EEC members has now expanded and continues to do so.  UKIP's leader Nigel Farage has made made statements about the numbers of potential migrants to the UK.  Again some of these statements are misleading.  Of course the sum total of theoretically possible migration to Britain can be calculated in simple terms by subtracting the UK population from that of the entire EU.  There is a theoretical possibility that everyone else in the EU would wish to migrate to live and work in the UK - theoretically yes, plausible no.

So there are two sets of disingenuous arguments: that we didn't sign up to a 'free movement of people' in the original EEC - yes we did because that too was a key freedom under the terms of the EEC.  Furthermore successive governments, including Tory governments continued to sign up to that particular freedom**.  Mrs Thatcher,  perhaps the most anti-EU prime minister, was more concerned with repatriation of 'our' money than with challenging the freedom of movement of peoples.  As she rightly said in her now famous Bruges speech setting out her perspective on the EU:

"And let me be quite clear. Britain does not dream of some cosy, isolated existence on the fringes of the European Community. Our destiny is in Europe, as part of the Community."

Our destiny is in Europe, as part of the Community.  What she meant by that was as part of the EU.  She went on to say that the  European Community "is a practical means by which Europe can ensure the future prosperity and security of its people in a world in which there are many other powerful nations and groups of nations."

For Mrs Thatcher the crucial role of the EU was to break down barriers to free trade and enterprise.

"The aim of a Europe open to enterprise is the moving force behind the creation of the Single European Market in 1992. By getting rid of barriers, by making it possible for companies to operate on a European scale, we can best compete with the United States, Japan and other new economic powers emerging in Asia and elsewhere."

Getting rid of barriers so that companies can operate on a European scale meant also removing barriers to the free movement of people.  Whilst she spoke of the need for national borders to prevent illegal immigration she made no reference to stopping the free movement of people across Europe.

Now those who want Britain out of the EU say that we never signed up to the free movement of people - Yes we did.

*EU citizens have the following main rights:
• The right of residence anywhere in the EU. EU citizens and their family members, including third-country nationals, may reside anywhere for up to three months. They may remain for over three months if they are working, if (in most circumstances) they have become unemployed or are in training; if they can support themselves otherwise; or if studying. They gain the permanent right of residence if legally resident in a Member State for five years;
• The right of free movement anywhere in the EU, including not to be deterred from moving to another Member State, and including the coordination of social security entitlements in accordance with the regime in Regulation 883/2004. The jurisprudence suggests that this provision even covers areas where the EU does not otherwise have extensive legislative powers;
• The right not to be discriminated against in another Member State. Again, this provision even covers areas where the EU does not otherwise have extensive legislative powers.

** The UK was a major driving force in generating political impetus behind reforms and pressed for the Single Market portfolio for the UK’s Commissioner, Lord Cockfield, in 1984. In 1985 the Commission submitted to the Milan European Council a White Paper, Completing the Internal Market, which argued for a new more dynamic strategy based on mutual recognition and on more legislative harmonisation. It listed 279 specific legislative measures to be brought into force by 1992, and proposed a series of Treaty changes to enable that to happen more swiftly. This essentially set the agenda for the Single Market as we know it today.