The Thin End

I suppose I can't resist saying something about HS2. At least it shows that, if the government wishes, it can find funds for infrastructure investment.  A plan B is possible. The public consultation about the proposed route was a farce. No environmental impact assessment had been carried out. So answering the questions was a stab in the dark. HS2, we are told, will 'transform journeys'. HS2 is forecast to carry up to 5.4 million passengers every year who might otherwise have travelled by air, as well as potentially seeing up to 9.8 million passengers transfer from the national road network. Those are big numbers. It might help cut the carbon footprint. I am not at all sure where they get these estimates from. Well I do really. They use an econometric model to project the numbers of air passengers, The Unrestricted Error Correction Model is one of them.  It has an equation that has a lot of Qs and Zs in it and a few bits of Greek alphabet. And it has been qui...

Cuts in NHS budgets are exacerbating the bureaucratic burden on front line staff. This is the warning given by the NHS Confederation in a report published last week. The NHS Confederation, a body representing all organisations that commission and provide NHS services, is worried that the current NHS reforms, by making the system more complicated, will increase still further the administrative burden on NHS front line staff. Government ministers have argued that the £20 billion cut in the NHS budget would not affect front line services. Yet, between May 2010 and September 2012 whilst the number of managers was reduced by 18 per cent and the number of clerical and administrative staff declined by 10 per cent,  a consequence has been an increased administrative load on doctors and nurses. If the administrative burden does not also fall, the report warns, there is a risk that front line staff will be diverted to form filling. Reorganisation has compounded the problem. Commissio...

I sometimes wonder when I listen to discussion about 'the unemployed' and 'getting tough', or about 'strivers' and 'shirkers'  whether we appreciate fully the seismic impact of the financial crisis on British businesses and jobs. In the space of 12 months in 2008/09 a staggering 220,000 companies went out of business with the loss of 1 million jobs.  What is needed is investment and the creation of new jobs. What is not needed is cuts in spending. Cuts in spending further contract the economy and increase the deficit in public finances through loss of tax revenue. The way out of recession is to get people back to work productively, spending in the high street and paying taxes. It all seems obvious. It isn't the equivalent of economics rocket science. Many have been saying it. The tragedy is the coalition and the political consensus signed up to the idea that the deficit had to be cut. The deficit was not the problem. It was if anything a symptom. N...

Labour's attempt this month to sound tough on benefits for the long-term unemployed is worrying. They are adopting a carrot and stick approach. Britain,   Ed Balls says , "needs real welfare reform that is tough, fair and that works." It is sadly familiar language. Labour says it will offer a "job guarantee" to the long term unemployed. Government will "ensure" there is a job for each adult who is long-term unemployed, and people will be obliged to take this job or risk losing their benefits. It sounds fair, a guaranteed job. But where would this job come from? There are currently around 130,000 adults over the age of 25 who have been out of work for 24 months or more. According to official figures unemployment now stands at 7.7% of the work force.  But unemployment is unevenly distributed across the UK. In the worst affected areas such as Ladywood and Hodge Hill in Birmingham it is as high as 10 - 11.7 %.   Unemployment in Birmingham is greatest ...

The government talks of 'fairness' in distribution of benefits.  But what is fair? During the boom years the poor got poorer, the middle class got richer. The biggest beneficiaries of government largesse have been the middle classes, not the poorest. Over the last decade, the relief on income tax and National Insurance Contributions totalled a staggering £358.6 billion. The middle classes benefited from tax exemption through personal equity plans and ISAs in which they were able to accumulate savings with tax free interest. The huge expansion of higher education from the 1960s onwards created educational opportunities for their children on an unprecedented scale, whilst the opportunities for the poorest were restricted. University education remains to this day largely a middle class preserve. The middle classes benefited from child allowances and expansion of nursery school provision. Until it was abolished by Gordon Brown in 2000, the middle classes benefited from mortgag...

In 2011 the Secretary of State for Work and Pensions, Mr Ian Duncan Smith set out a ' new approach to child poverty' . At its heart he says are the principles of "work, fairness, responsibility and support for the most vulnerable". It is set to fail;  and the reason it is set to fail is because the underlying assumptions are wrong. At its heart is the idea that the cause of poverty is that people don't work. It adopts a carrot and stick approach based on the notion of "welfare dependency". It sets out to "reward those who work". The flip side of the policy is to punish those who do not. It seeks to drive feckless people into work by cutting their benefits. The poor are to be blamed for their poverty. It adopts a Victorian approach with the assumption that poverty is to do with behaviour. If only the poor would adopt different lifestyles, the idea runs, then they could 'help themselves out of poverty'. It raises the image of drug a...

There are some no doubt who won't really care about the poor in the UK until they are homeless in the streets with bloated starvation bellies. I guess it will wait for a 'live aid' concert by rich pop stars with crass lyrics to tell the world that the poor in the UK need feeding. Since writing my piece on the cuts in benefits driving 200,000 more children into poverty, at least a few have questioned me about 'what real poverty means'. It is the 'yes but' kind of argument. Poverty they say is 'relative'. No it is absolute. It is absolute because of its effects on inequality and opportunity. Poverty, particularly in childhood, produces a cycle of poor health and lack of opportunities to break out of the chain. Poor health blights a generation through poor educational attainment and poor job prospects. Poverty, bad housing and undernourishment create a cycle of poverty handed on across generations. The cost of the coalition's policies is difficult...

The government now acknowledges that its squeeze on tax credits and child benefits will push 200,000 more children into poverty. Ministers argue that it is no longer a valid measure of the impact of their policies. But child poverty matters; it matters a great deal because it represents a crucial link in the chain of poverty and ill-health. The impact of child poverty is transgenerational. The problems of poor health are likely to affect the next generation too. The health costs to the nation will far outweigh the relatively paltry savings made now by cutting benefits. Yet the impact of the cuts is immense. Standardized Mortality Ratio  data from bmj; 1993; 307;1519-24 A simple measure of the likely effect of child poverty is to consider the impact of undernourishment during development and early childhood on the risk of cardiovascular diseases in later life. One such measure is represented in the standard mortality ratio of adults born small and undernourished compared ...

Prince Charles has been at it again. This time he has written an article published in the current Journal of the Royal Society of Medicine (JRSM) in which he advocates an "integrated approach to medicine and health." Prince Charles defines an 'integrated approach' as being "an approach to care of the patient which includes mind, body and spirit and which maximizes the potential of conventional, lifestyle and complementary approaches in the process of healing." Whilst I might disagree with him on some of the detail, and we certainly wouldn't agree on some alternative medicines such as homoeopathy, nevertheless I am in complete agreement with the core thrust of his argument. A distinguishing feature of modern medicine is that it is 'evidence based'. This is as it should be. Patient trust requires that medical practise and treatments are based on knowledge and some kind of fundamental and tested principles. But for too long medical science ha...

There is growing concern that the NHS might be at a tipping point, with top down reorganisation and massive cuts to budgets. In a previous article   I argued why it is disingenuous for the government to claim that £20bn cut in the NHS budget could be made without affecting front line staff, doctors, nurses and vital technical support. The claim that 'streamlining' efficiency savings could be made without cuts in front line staff is wrong. The government knows this of course. But it doesn't stop them repeating the falsehood. There is increasing evidence that cuts are affecting patient safety. According  to rulings by the official safety watchdog,  The Quality Care Commission, 17 hospital trusts have dangerously low numbers of nurses. The Royal College of Nursing has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." Nurses say that they "d...

Here we go again. Groundhog day. From April  new rules are to be set for qualification for disability allowance or personal independence payments (PIPs) as they are to become in April.  The new assessment according to the Department for Work and Pensions (DWP) "will focus on an individual’s ability to carry out a range of key activities necessary to everyday life." Information will be gathered from the individual, as well as healthcare and other professionals who work with and support them. Most people will also be asked to a face to face consultation with a trained independent assessor as part of the claim process.  From the experience of the Work Capability Assessment, it looks like another recipe for pain and suffering.  I often wonder who it is that draws up disability or capacity criteria. What kind of person is it that decides if you can go up two steps without being in pain you are 'fit'? What about the third and fourth or subsequent steps? Of course I ...

William Harvey 1578-1657 Often our ‘gut instinct’ is to take a particular course of action but our ‘rational mind says no’, and often in hindsight we wish we had followed our ‘gut instinct’.  The heart figures prominently in our cultural expression of emotions. It is in our poetry and our literature. But is there a physiological explanation for this? Can the heart once again be centre-stage of our feelings? Do we really have ‘gut’ instincts? In a three-part series of videos by Voices from Oxford , Professor David Paterson, Associate Head of Medical Sciences at Oxford University, explores with Denis Noble a paradigm shift in the way we think about our heart and brain and the intimate neural connections between the two.  Appropriately the filming is at Merton College where, as a result of the 17 th Century English Civil War, William Harvey was briefly Warden. Harvey revolutionised our understanding of how the body works by describing the role of the heart as a pump, ...

The news last summer that some hospitals were having difficulty meeting their financial obligations under their PFI arrangements led to speculation that hospital Trusts would fall into receivership like a row of dominoes. I have not been enthusiastic about the use of PFI in the NHS. I am, however, sceptical of some of the scary stories about how much they are costing and how big a problem they are. It is easy enough to take a few cases where there are problems, and there are some, and create a myth that they are inherent and endemic. Where there are problems, they are usually specific to those Trusts. The left have always been sceptical about PFI if only because of the Private bit of the 'initiative'. It is regarded a bit like unsafe sex; unprotected, it could lead to unwanted consequences. A key question is not whether the scary stories are true but whether they are typical and what the  explanation for them might be. Information collated by the National Audit Office ind...

I started the week by considering how the wrong message had been taken from the Olympics and Paralympics. In ' If we invest in people we can win ' I argued that medals had been won because support was given to the particular sports and to the individuals. If you invest in people you can produce winners. Hard work alone wasn't the key to success. Contrary to the portrayal by Mr Cameron and his colleagues, the majority of those receiving welfare benefits are hard working and dedicated, day in and day out. But, for the poorest of them, he is cutting their support. They are winners and yet he is taking away from them the support they need to go on being winners; bread winners for their families. It really is a very cynical move by the government. They are making the poor pay the most for the mess the bankers got us into. I suspect  from their divisive rhetoric, Mr Duncan Smith offers a disingenuous and divisive comparison ,  the assumption is that protecting middle income gro...

A paper published this week in the Annals of Oncology has demonstrated bias in the reporting of  outcome and toxicity of phase 3 randomized controlled trials (RTCs) for breast cancer. These trials are the final stage of testing of the efficacy and toxicity of a new drug or treatment before approval by regulatory agencies. Papers published in scientific and medical journals have an abstract, a summary of the findings, and it is in this that the results are often presented in a biased way. Of the reports of 164 trials they reviewed, 33% of them showed bias in the reporting of the primary end point (PE) and as many as 67% in reporting the toxicity. Bias in reporting of outcome is common for studies with negative PEs.  Reporting of toxicity is poor, especially for the studies with positive PEs. It isn't that the authors don't give the correct result in the body of the report. The problem is that they put a 'spin' on them.    It is shocking but perhaps the finding...

In a previous article  this week I argued why it is disingenuous for the government to claim that £20bn cut in the NHS budget could be made without affecting front line staff, doctors, nurses and vital technical support.  The claim  that 'streamlining' efficiency savings could be made without cuts in front line staff is wrong. The government knows this of course. But it doesn't stop them repeating the falsehood. The  Royal College of Nursing   has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." N urses say that they "do not have enough staff to deliver good quality care. Demand for services is continuing to rise, however staffing levels are being slashed."   Looking around the country and the reality is revealed. At the Royal Bolton Hospital 500 jobs are to be cut with further savings being considered by changing the co...

“Do you have pets at home?” The client answered in the affirmative, so the records show that the client, “Feeds and cares for dog without difficulty”. The truth was their pets were cared for by their children. This is from an account given by the Citizens Advice Bureaux (CAB) in their evidence to the third year review of the Work Capability Assessments. It is one of many statements from their clients experiences of WCA.  In yet another case it was reported a  "client sought advice as the HCP recorded no abnormality and no problem with hands, despite the client having visibly swollen and deformed hands, with a consultant rheumatologist report confirming this." Anecdotal, yes. But anecdotal evidence can be powerful when the sum total creates a coherent and meaningful testament; when each voice like a thread weaves a tapestry that is compelling and authentic. When there are common features to each narrative. "They did not listen." "They moved on to the next ...

Some time ago, actually it was a long time ago when I was in my early teens, someone close to me bought a table. It was an early flat pack variety. It came with a top and four legs. He followed the instructions to the letter screwing the legs into the top. But when he had completed it the table wobbled. One leg he explained was shorter than the other three; so he sawed a bit from each of the other legs. The table wobbled. One leg, he explained, was longer than the other three. So, he sawed a bit off. The table wobbled. He went on cutting the legs, but the table continued to wobble. Cut, cut, cut! By this time he had convinced himself there was no alternative to it.  He ended up with a very low table indeed, supported by four very stumpy legs and a bit of cardboard placed under one of them to stop it wobbling on the uneven floor.  Mr Duncan-Smith argues that we need a 1% cap on benefits to be 'fair to average earners'. Average  earners have seen their incomes rise by le...

There is an assumption often made in debate on the NHS. It is said there are too many managers. It is an assumption rarely supported with any kind of evidence. It is one of those ideas we just have to go along with. If you suggest otherwise people will think you are an idiot. So, we just go along with it. But is it true? The truth is I have no idea, but I suspect neither does anyone else, although there may be one or two 'experts' in the field of man management who do. But it is a very dangerous assumption. It is important of course because the other idea we hear a lot is that 'cuts won't affect front line services'. The truth is, despite pledges given by the government, the NHS has already lost over 6000 nurses. But why would anyone take seriously the idea that cuts would not affect the 'front line'? The reason is the assumption, you see, that there is so much management and 'back office staff', that these could be shed instead. Now if you beli...

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

It seems a bit late to talk about the Olympics. That was last year's news. But I was always concerned we would take the wrong message from the Olympics and Paralympics.   It has been revealed that half a million soldiers, nurses and teachers will have their incomes slashed in the coalition's benefits crackdown. That is half a million 'strivers'; half a million winners. Mr Cameron clearly has learned very little from the Olympics. If you want winners then you have to support them.   Like many others I was enthralled by the wonderful success of British athletes. Each day I would clap with joy at each new medal added to the tally. I didn't expect to be so riveted by it all. "Isn't it fantastic?" friends and relatives would say. And I would say "Yes! Fantastic! Wonderful!" But even as I expressed my enthusiasm, I had nagging doubts. Not doubts that it was fantastic, or about the effort and achievement of the athletes. I shared their joy. I shar...