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.

Thursday, 12 November 2015

Chocolethics - the unfair global market in cocoa

Consider this when next you pick up a bar of Cadbury's Fruit and Nut or a Mars bar, conveniently sold cheap at your supermarket checkout, the amount it costs you is the amount the cocoa picker gets for a whole day's work.  

In 2014 total global  sales of chocolate confectionery reached a staggering $100 billion  - an increase of 20 billion from 2012 ( Euromonitor International).  Very little of this money reaches the cocoa farmers and pickers who receive around $1.25 dollars a day for their efforts.  They work a whole day for the price of a chocolate bar in the UK or USA. 

While the profits of multinational chocolate companies have increased since the 1980s, the world market price for cocoa beans has declined by half with the cocoa producers receiving less and less of the massive turnover.  Nevertheless the price of cocoa can fluctuate in an insecure market affected by weather and harvests. With increasing demand for chocolate globally most recently chocolate producers have faced increasing commodity prices  as demand outstrips supply, leading to different marketing strategies such as reducing the size of a bar or the number of chocolates in a box. At the other end, the cocoa producers are at the mercy of big market intermediaries and have to accept the price offered, leading to economic insecurity and impoverishment for millions of cocoa farmers.

But much of the problem lies with the producers who have failed to invest in more efficient production or give support to struggling farmers. Disregard for the livelihoods of more than five million small-scale family farmers who grow 90% of the world's cocoa means that the industry may simply be unable to provide sufficient supply to meet the demand by 2020. Prices of chocolate is rising but these famers are not receiving any increased share.

Growers  will receive just 3.5% to 6.4% of the final value of a chocolate bar -  a fall compared with 16% in the late 1980s. The manufacturers' share has increased from 56% to 70% and the retailers' from 12% to 17% over the same period.  Something is wrong in the way the markets work. They certainly don't lead to an equitable distribution of revenue and investment.  Chocolate production has increased meeting ever rising demand, a demand fuelled by massive promotion of then end products, while little of this has filtered down to the producers.  It is a distorted market with big intermediaries dictating terms to the farmers.

Meanwhile massive amounts are spent on promoting chocolate.  Last year Cadbury spent £7.5 million in a one week promoting its new Dairy Milk Ritz and Lu products in the UK.  Mondelez International is little known in Britain, but is now the multinational corporation behind Cadbury. Mondelēz International has annual revenue of approximately $36 billion and operattes in more than 80 countries.  

Chocolate production has yet to prove good for the struggling farmers, but is it good for the consumer?  Some evidence suggests it is. 

Diet is a key lifestyle factor involved in the genesis, prevention, and control of cardiometabolic disorders. Cocoa products containing flavonol have been shown to have an encouraging potential to help prevent cardiometabolic disorders, and several recent studies have suggested that chocolate consumption has a positive influence on human health, with antioxidant, antihypertensive, anti-inflammatory, anti-atherogenic, and anti-thrombotic effects as well as influence on insulin sensitivity, vascular endothelial function, and activation of nitric oxide all of which are involved in cardiovascular function and disorders.  Higher levels of chocolate consumption were associated with a reduction of about a third in the risk of cardiometabolic disorders in a meta-analysis from several studies.  Several other studies have also shown a similar link.  But what these studies do not do is promote excess chocolate consumption, particularly where it is mixed with the possible harmful effects of excess sugar intake.

Whilst chocolate consumption might have healthy benefits, it is a bitter sweet in relation to the environment.  With lack of investment and support for good farming increased cocoa production is a threat to the environment with soil erosion, pesticides, deforestation and a threat to wildlife. It comes with a heavy cost in social terms and exploitation of farmers. 

Wednesday, 11 November 2015

Neoliberal myths of a free market

Neoliberalism has been the dominant creed in recent times. In one form or another it has underlined economic strategies followed in the UK by both Labour and Tory governments. New Labour embraced and worked with it. It seemed that global capitalism had won the day in the post-war conflict of ideas, and despite the banking crisis, it continues as the dominant influence.

If measured by the accumulation of wealth and the developments of new technologies it might be regarded as a success. But the cost of that success has been a heavy price. Socially it has failed, and the cost of that failure has damaged the environment increased inequalities. But who benefits from it? Who is it for?

Some 3 billion people live on less than $2 a day whilst 86 percent of the world’s resources are consumed by the world’s wealthiest 20 percent. That is the success of the neoliberal myth.

When government chooses not to ‘intervene in the market’ it is making a political not an economic decision. The neoliberal view assumes there can be a ‘free market’ where there is no government or public intervention. It believes that aggregate individual good is social good. The ‘free market’, the argument goes, settles everything through price – if only it was left alone to ‘do its job’. This view has a simple underlying philosophy – that there is no ‘social need’, only private or individual need.

Society is regarded as an aggregate of individuals. Any expression of ‘social need’, as for example in health or education, becomes, in this view, a distortion of this ideal ‘free market’. Neoliberalism contends that the free movement of goods, resources and enterprises will always find cheaper resources and maximise profits and efficiency.

Neoliberalism specifically rules out the role of the state in regulating such markets. It is against Tariffs, Regulations, standards, laws, legislation and regulatory measures and restrictions on capital flows and investment.

This neoliberal view tends to ignore that individuals have little weight in determining ‘market price’ against big global corporations. The market is in that sense badly distorted between consumer and producer. Behind so many brands in food there are just 10 big global corporations with revenue of tens of billions of dollars. They dictate the market and have food producers under their thumb. Nestle had more than $100 billion in sales and more than $11 billion in profits in 2013.

These big giants create the needs or markets as much as respond to them. They are the largest media spenders in the world spending huge sums on branding and marketing - Mars Inc. for example spends over $2 bn on advertising; Unilever spends over $7.5 bn. Their ability to manipulate demand and ‘brand awareness’ outweighs that of their competitors. These big corporations are big lobbyists of government when it comes to food and health policies. Their activities have huge impact on environment, health and workers rights.

Four giants dominate the raw materials of the global food system. These giants, big as they are, operate below the radar of the average consumer. Most will not have heard of the group known as the ABCD group for the alphabetic convenience of their initials - ADM, Bunge, Cargill and Dreyfus – but they are estimated to account for between 75% and 90% of the global grain trade.

The neoliberal view has also another underlying assumption, that there will be some kind of equilibrium where the free market distribution will produce an optimum distribution of goods. It makes the assumption that the only distorting player could be the state, yet globally and nationally major corporations are players bigger than any state influencing the market. The market is not ‘free’ in the sense of being without big players.

Four giants dominate the raw materials of the global food system. These giants, big as they are, operate below the radar of the average consumer. Most will not have heard of the group known as the ABCD group for the alphabetic convenience of their initials - ADM, Bunge, Cargill and Dreyfus – but they are estimated to account for between 75% and 90% of the global grain trade.

The rise of global capital controls markets in ways that individual states cannot. Economic policy is at the whim of global capital. Global capital is often expressed in terms of the ‘free movement of capital’, yet the movement of capital is not free of big corporate decisions. What ‘free movement of capital’ really means is that it is not controllable by any state or government.

A handful of players dominate, not just in primary agriculture but in food manufacturing and retailing. The result, according to Oxfam, is that "they extract much of the value along the chain, while costs and risks cascade down on to the weakest participants, generally the farmers and labourers at the bottom".

This is not a fair or free market. It is a market where a small group globally dominate and take action to determine the ‘market’. When health issues are raised about food, they are powerful lobby against change.

It is a market where the primary producers are suffering loss whilst the big fish gain. Think while we drink our cups tea and coffee of where and how it is produced. Cocoa growers now receive just 3.5% of the average retail value of a bar of chocolate. In the 1980s they would have received 18%. Here in the UK farmers are going out of business because the big supermarkets won’t pay them a fair price. The food giants rule the market.

Monday, 9 November 2015

Osborne now targets universal credit in his attack on the poor.

What does it take to get this government to realise the suffering they are inflicting on those reliant on benefits.  Failing to get his way with cuts in Tax Credits it is now suggested that the Chancellor, George Osborne has now his sights on cutting the new universal credit.

Apparently, the Work and Pensions Secretary has threatened to resign if the Chancellor cuts the new benefit.

Universal credit was launched by Mr Duncan Smith  with great fanfare in 2013, combining previous means-tested benefits such as jobseekers allowance, tax credits and housing benefit into a single payment which is currently being phased in across the country.

It is a controversial scheme, not least because it makes the assumption that benefit need is uniform and not specific to circumstance such as mental health. Universal Credit will mean people with mental health issues will no longer have their claims supported by a specialist health assessment but instead through meetings with a general job centre work advisor.   

Such a move is likely to be detrimental to those with mental health issues as they are often the least likely to be picked up in a general assessment by an unqualified advisor.  There is no system in place at job centres to provide such professional advice.  It is already clear from those on the Work Programme that it is making their health issues worse.  The DWP refuses to reconsider the impact of the new assessment on those with mental health issues.  They wish to remain blind to the problem and ignore the concerns expressed by organisations such as the mental health charity MIND.  

Instead we have Lord Freud, the Government’s welfare reform minister, proffering the incredulous notion that Universal Credit would make life easier for mental health problems because 'generic work advisors would become more adept at dealing with mental health issues'.   The suffering of those wrongly assessed will no doubt be a lesson to those making the assessments!

Universal benefits has some cross party support, but the devil is not so much in the detail but in the purpose.  I am always wary of the all embracing reason given for changes in benefit that it is 'to make work pay'.  What that translates into is more people being forced into low paid, insecure jobs. We create a cycle of 'dependency' - locking people into low pay jobs.  

Nonetheless, the Work and Pensions Secretary is concerned that change in universal credit, particularly if it affects the tapering of the benefit will mitigate its intention.  Currently the taper is set at 65% – meaning that for every extra £1 claimants earn above a threshold, they lose 65p – but Osborne is looking at a proposal to increase this to 75%.  

But all this begs the question wether there should be cuts in benefits at all.  The government says it is necessary to 'cut the deficit', but if that is so then why did Osborne cut tax on beer? If he intends to cut the deficit then revenue should be considered.  The stated imperative of cutting the deficit is not consistent with cutting such taxes. It was a cynical move to win votes. 

The government argues that the benefits bill is 'out of control', but you can't have a system designed to 'make work pay' and then grumble about the cost of it.  The cost is increasing because too many people are pushed into low pay. 

The best way of tackling the benefits bill is to increase pay.  Duncan Smith was delighted by Osborne’s decision to announce a national living wage in the summer budget, and famously responded to it with a double fist pump in the Commons.  For once I can agree with him that a move to a genuine living wage is what is necessary to lift people out of poverty and benefits. 

We need a budget for growth not a budget that hurts the poorest.  We need a budget that encourages proper contracts and skills, not one that pushes hard working people deeper into poverty.  We need a budget that tackles the cost of housing, a major factor in poverty, and a major hindrance to jobs. 

It is time the Chancellor understood you can't cut your way out of a crisis -  crisis of his own making.  But you can stimulate real economic recovery and productivity growth, creating more jobs and rejuvenating many areas of industrial decline. 

Lifting people out of poverty with decent wages and jobs is economic sense. Pushing more people into poverty is economic madness. 

Thursday, 5 November 2015

Labour can become the progressive force for change

In a previous article I laid out the background to my own political compass. The belief that there is  something fundamentally wrong with a society predicated on vast inequalities, not just in the distribution of wealth, but also of opportunities.  For too many decades we have accepted that the interests of the poorest are inextricably woven into making the wealthy richer. Rather than being appalled by the enormous wealth concentrated in the hands of so few, we are asked to reify it - cast it in political stone.

There is a kind of impossible dream scenario that holds because some people become rich everyone else could too 'if they tried' or put their mind to it, or became entrepreneurial. There is a minimum of truth in the tale, but it is a false prospectus. It is a prospectus that holds the poor responsible for their own poverty. In recent decades we have worshipped those who make money rather than those who create things, or at best we have left  unquestioned the way in which such wealth is accumulated. When the accumulation of wealth becomes an end in itself you have to question what it is for. When wealth creation is predicated on abusive exploitation of the poorest, then it is a matter of social justice.

I should say that I have no problem with people being very rich. I do have a problem with some being very poor and with the way the poor are treated, and I do have a problem with how wealth is accumulated.

The society in which I grew up was palpably unfair.  Much has changed since, but the vast inequalities of opportunity persist.  The Labour party must once again find a clear voice to address poverty and inequalities of opportunity. Social justice must once again form the core of what Labour is about.  But that requires, not simply a wish list and bashing the rich, but  the development of a coherent strategy for government. 
Labour is nothing if it is not a crucial part of the movement that challenges unfairness, or as Harold Wilson  would put it a 'crusade' against poverty.  But whilst the problems are old, old solutions will no longer work - not least because voters won't accept them. A simplistic message of tax and spend is not one voters will support. Or at least they show no appetite for such an approach.  This presents a dilemma for Labour.  It cannot be addressed by ignoring the problem. We need a new narrative. 
Curiously, Mr Cameron is right for all the wrong reasons.  Tackling poverty is predicated on a growing economy and wealth creation. That is necessary; but it is not in itself sufficient. Unless there are profound structural changes in the economy, then a growing economy simply makes the rich richer. Growth predicated on making the poor worse off, as will be the case under this government, is simply an unfair economic settlement.

Growth predicated on cuts in welfare is simply making those with the greatest need pay for the wealthy - a further redistribution from the poor to the rich. This was the approach of the previous, coalition government and now the Tory government. Trickle down economics if successful at all is simply that, a trickle, a drop in the ocean whist the gap between the rich and the poorest grows ever greater.

We don't need trickle down. We need a lifting up, with a genuine approach to fair earnings and fair costs. We need to move to a genuine 'living wage' with concrete policies to enable this. Just as occurred with the introduction of the minimum wage, there will have to be supportive measures to ensure it doesn't affect jobs.  We will need to work with businesses to ensure this works. This is one reason why Labour must work with and not generate a negative narrative about business.  Labour is the party of business because it wants to put people back to work with genuine jobs, and to develop the skills needed to make businesses grow and be competitive. Labour is the party of business because it wants to create sustainable growth.  We need to harness growth but also ensure that it is the ordinary working people who benefit from that growth. There is no reason for this to be business unfriendly. Moving to a living wage makes economic sense. It is key to deficit reduction. Tackling the causes of benefits is the best way  to decrease the welfare bill and reduce the deficit. The causes of the benefit bill going up are low wages and job insecurity coupled with high housing costs.

Moving to a living wage will in its turn reduce the benefits bill and increase tax revenues. The arguments for cuts in tax credits provided by the Tories are at best disingenuous, at worse purposefully deceitful. They put the cart before the horse. A living wage in 2020 doesn't compensate for cuts in benefits now. It is a false and deceitful prospectus. It is a political trick - a trick that went wrong for the government.

We need a fundamental change in the balance of power and privilege. We need a society predicated on fairness, and not one predicated simply on 'wealth creation'.  Wealth creation is essential but it is also necessary to ensure all have opportunities to benefit from it. This is why we need to address the distorting effects of the unfettered housing market and extortionate rents.  Once again, if we tackle rents we will reduce the benefits bill.  Social justice is good economics.

We need to address the housing shortage by building affordable homes and generating social housing - housing for homes, not for profit.  Is it affordable? Yes. The cost of HS2, which many argue is unnecessary and damaging to the countryside, is estimated at £42 billion.  Building social housing for rents working people can afford will help lift people out of poverty and provide opportunities for young families. The cost of not doing this will be ever spiralling housing costs pushing decent homes out of reach of ordinary families.  It will also stimulate the economy providing jobs and infrastructure. It will increase tax revenues and draw down the deficit and national debt.  This is investment for sound social and economic gain. It is sensible economics.  We pumped in billions to rescue the banks, we need now to invest to build the real economy, providing jobs and prospects for our young people. 
This is why we need to hear more about our social aspirations - better educational opportunities for all our children, better housing for all our families, better hospitals and social care for all our people. This can be done, not by get-rich-quick economics founded on an insecure housing boom and private debt, but by growth and investment in skills to meet the demands of the 21st century. Labour can be the party of progress, once again transforming Britain.

The dragon that will not roar is taxation. Labour needs the courage to talk about redistributive policies. This does not mean punitive taxes. It means fairness in the tax system.  Austerity has meant that the poorest have paid the price for the banking collapse.  That is unfair.  A further £12 billion of cuts in benefits will hit them further.  This is unnecessary and unfair.

The poorest 10% pay as a proportion of their income  more in overall taxes than do the top 10%.  Indirect taxes hurt the  poorest most and effective marginal rates make advancement difficult and this iw is why we must address the issues at these margins. 
Wealth creation and redistribution are not mutually exclusive. Labour needs to develop a distinctive message that will appeal to a broad section of voters who I believe are fed up with our politicians dancing on a pin head. 'They're all the same' should be countered with 'oh no they are not'. 
This is not a question of 'left' versus 'right'. Labour has become trapped into avoiding the central issues they should be challenging because they have been afraid of being seen to shift left. But I have met many people who want to tackle unfairness, injustice and poverty and who would not regard themselves as 'left wing' or even socialists. 
I recall a seminar at Balliol College Oxford back when the 'gang of four' had set up the SDP breakaway from Labour. The invited speaker, Shirley Williams,  made the point that the problem with Tony Benn was that he wanted an irreversible shift in the balance of power and privilege. She regarded the 'irreversible' bit as indicative of an undemocratic society. It was an interesting point of political philosophy. Yet surely the purpose of the Labour party of which she had once been a leading member was, and is, to bring about a fundamental shift in the balance of power and privilege.  But what kind of democracy is it that is based on an effectively irreversible inequity in the balance of power and privilege? What kind of society is it that can allow the poorest to get poorer whilst the rich get richer? 
All this is why Labour must challenge the premise that massive cuts in benefits are necessary to 'cut the deficit'. They are not. What is necessary is to increase revenue. Making the poor poorer in the end increases the burden on the health service and increases welfare dependency not reduce it. It is the cuts in social care in the last five years that have produced the biggest strain on the NHS.

To blindly target £12 billion of cuts in benefits without having considered where they would fall and what the consequences would be is a shocking indictment of the government strategy. Labour should have none of it. Labour needs a clearer message and voice for that message. It must now develop a new narrative for change. Labour can once again become the progressive force in British politics.

Tuesday, 3 November 2015

Stop playing media games Mr Hunt and talk on junior doctor contracts

BMA responds to Guardian story on Jeremy Hunt's offer to junior doctors

It is reported in the Guardian today that Health Secretary, Jeremy Hunt is to offer junior doctors an 11% pay rise in a last-minute bid to stop them going on strike just as the NHS is preparing for its most pressured time of year.

Responding to the Guardian's story the BMA, the doctor's representative body,  has said that it has not been given any information other than that being released 'piece meal' to the media and challenges the government to provide reasonable assurances and details rather than engaging in "megaphone diplomacy". 

The BMA has told the Government that it wants to work with them to agree a new contract, but that it needs a number of concrete assurances in order to do so. These assurances are:

  • withdraw the threat to impose the new contract
  • proper recognition of unsocial hours as premium time
  • no disadvantage for those working unsocial hours compared to the current system
  • no disadvantage for those working less than full time and taking parental leave compared to the current system
  • pay for all work done
  • proper hours safeguards protecting patients and their doctors
 Dr Johann Malawana, BMA junior doctors committee chair, says in response to the Guardian report:

“Junior doctors need facts, not piecemeal announcements and we need to see the full detail of this latest, eleventh hour offer to understand what, in reality, it will mean for junior doctors. We have repeatedly asked for such detail in writing from the Secretary of State, but find, instead, that this has been released to media without sharing it with junior doctors’ representatives. What we do know, however, is that Jeremy Hunt has repeatedly changed his position on pay and just last week was caught out trying to gloss over the truth when he said that no doctor would have their pay cut, only hours later to admit that those working the longest hours would in fact see a reduction in pay.

“The BMA and junior doctors have been clear that we want to reach a negotiated agreement with the government on a contract that is good for patients, junior doctors and the NHS. In order to do this we have said, repeatedly, that the government must remove the threat of imposition and provide the concrete assurances junior doctors have asked for on a contract that is safe and fair.

“We are clear that without the assurances we require, the BMA will be left with little option but to continue with our plans to ballot members. The government have so far failed to provide these reasonable assurances, preferring instead to engage in megaphone diplomacy and plough ahead with plans to impose a contract that would be bad for patients as well as junior doctors.”

The BMA also point out that the Health Secretary has repeatedly changed his position on junior doctor pay.

According to the Guardian some junior doctors have already rejected Hunt’s offer. One told the them: “The sugar coating is Hunt will increase base pay by 11% but the bitter pill is the cut on our of hours pay. This will result in a net loss of 20-30% regardless of his token 11% increase in base pay. Furthermore, they will abolish incremental pay so we get paid lower rates for longer. He has conceded nothing.”
In an interview with the Independent newspaper at the beginning of October Jeremy Hunt said: “It is not my intention to cut anyone’s pay”. In a subsequent letter to the BMA he said that “average pay for junior doctors will not reduce”.

In a letter last week to the BMA he said that “that no junior doctor will see their pay cut compared to their current contract” but admitted the following day that a “small minority” would see their pay reduced.  

If the Secretary of State is genuine about negotiating with the BMA then he needs to be more transparent and stop playing media games.  It looks as if Jeremy Hunt is seeking not so much to reach a settlement but to undermine the junior doctor's case.  The BMA has repeatedly stated it wants to come to an understanding with the Secretary of State. It is time he stopped playing games and talked to the representatives of the junior doctors.

Women and Children bear the burden of bombing in Syria

Prime Minister, David Cameron, has backed off presenting a vote in the House of Commons  on military action in Syria in face of clear opposition from the Labour party.  With some sceptical of the value of military action on his own side, he would likely lose such a vote.

But the Foreign Affairs Committee has also warned that any benefits of air strikes in Syria would be more than outweighed by the risks of  "legal ambiguity, political chaos on the ground, military irrelevance, and diplomatic costs".
The Committee concludes that 1) while intervention would be welcomed by the UK's military allies, in particular the USA which is now putting in boots on the ground in a limited capacity,  it would be likely to have only a "marginal effect" on the conflict. 

2) The UK risks "further reputational" damage unless it can make a clear legal case for action, with a UN mandate the clearest basis. 

3) It is unclear what the outcome would be and it is  "hard to predict" the consequences of tackling IS alone, and who might take their territory if they are defeated. 

4) Furthermore, Russia's  intervention has "complicated even further" any proposed UK action

There is an unpalatable conclusion we can come to.  Military engagement by the UK would make a marginal difference if any, but unless there is a clear target it would be as likely to perpetuate rather than end the conflict. 

Putin's goal is simpler: taking military action to support Assad.  In that sense, the precise enemy 'target' is definable - any group against Assad. This has the merit of combating ISIS but by also targeting any rebel threat to Assad remaining in power.  The US and its allies are unwilling to bite on that unpalatable truth.  If you want to defeat ISIS you might have to support Assad. It is a devil and the deep blue sea type of choice. 



If military action perpetuates the conflict, then that too comes at a dreadful price. Perhaps it is time the UK dropped its aim of removing Assad as a requirement for a settlement. 

Perpetuating military action is having devastating effects, and in particular on women and children who, a recent report in the BMJ showed,  bear a disproportionate share of the burden of bombings in Syrian conflict

Explosive weapons such as bombs and missiles, are the most lethal on women and children.

The study is the first to analyse the impact of different weapons on civilians and indicates that using explosive weapons in populated areas in Syria “has disproportionate lethal effects on women and children and should be urgently prohibited.”  Prohibition, however, is difficult without the means to enforce it in a bitter and increasingly violent war.

A report commissioned by the United Nations found that from March 2011 to April 2014 there were almost 200,000 verifiable violent deaths of individuals, including both combatants and civilians.

The study led by Debarati Guha-Sapir at the Université Catholique de Louvain in Belgium, examined 78,769 civilian violent deaths that occurred in Syria from March 2011 to January 2015 for associations between weapon types and demographic groups.

Of this total, 77,646 deaths were in non-state armed group (NSAG) controlled areas and 1,123 were in government controlled areas.  The majority of deaths were men, but the finding shows that nearly 25% of Syrian civilians killed were women and children.

The results show that children are more likely to be fatal victims of air bombardments, shells, and ground level explosives than men or women.

In government held areas, child deaths were 5 times as likely to be due to ground level explosives, such as car bombs than deaths among men.

Women were the second most likely to die due to explosive weapons, while the likelihood of death for men was higher for shootings and executions.

The government and rebel factions in Syria typically claim that the targets of their bombs and shells are enemy combatant strongholds, but the report shows “for Syrian children these are the weapons most likely to cause death.”

They argue that air attacks and explosive weapons in populated areas “should be prohibited or systematically monitored to demonstrate civilian protection.” Furthermore, the evidence that child deaths from air bombardments, shells, and ground level explosives were equal or higher than those caused by chemical weapons, should prompt equal international condemnation and control, they add.

“Our study shows that civilians become the main target of weapons and bear a disproportionate share of the burden of bombings. If we are looking for root causes of the migrant and refugee crises in Europe today, this is surely a major contributor,” conclude the authors.

Hamit Dardagan, Co-director at Every Casualty Worldwide, says these findings “should give pause to anyone who thinks there can be a safe hiding place for women and children when high explosives are being used in populated areas, or who imagines that Syria’s many bombed-out apartment blocks must have first been emptied of civilians.”

It also underlines the urgency of growing moves to ban the use of such indiscriminate weapons in populated areas. But again begs the question of how this would be imposed. 

So we are left wringing our hands.

Postscript: Mr Cameron is pressing hard for a vote in parliament to approve UK engagement in the bombing of ISIL in Syria, extendng the military engagement in Iraq across the border.  The Labour party is split on the issue.  But what is needed is a proper military engagement with troops under UN mandate to remove ISIL and protect the civilian population.  With bombing alone the outcome is uncertain.  The House of Commons Foreign Affairs Committee has put a series of questions which need to be answered by the government before military action is approved.  The Labour shadow cabinet should call on Cameron to make clear how military engagement would be made to remove ISIL and protect civilians.  Any engagement should be under UN auspices and mandate on the ground.