Tag Archives: NHS

Cameron’s “Big Society” – More Profit, Less Caring

David Cameron retreated to the relative safety of the Telegraph this morning to explain how he plans to completely revolutionise the provision of “public” services. Let’s skip over the fact that he a) didn’t tell anyone about this during the election and b) didn’t win. This is more of the desperate rushing towards change which Cameron feels obligated to do after Blair was criticised for not doing enough early in his premiership.

Cameron says he will introduce “a new presumption… that public services should be open to a range of providers competing to offer a better service.” He doesn’t talk about the level of service that people should expect, only that the government should ensure “fair access”. Where budgets are devolved (and failing) and private providers are allowed to operate where they choose, this heralds the end of our “national” health, education and social services as we know them.

Cameron feels obliged to talk about co-ops and mutuals bidding for new contracts, but when budgets are squeezed, these groups of local workers won’t have the infrastructure and resources to step in. They certainly will struggle to find the time to run the services as well as provide them. Therefore the door will be wide open for established – often foreign – providers to snap up contracts where they feel they can make money. They can take advantage of economies of scale and loss-leaders which small, local providers simply won’t be able to match. Are they likely to be hunting for contracts in difficult areas of country? Not unless the government ensures that resources are heavily weighted towards those areas, with enormous subsidies to make operating in unhealthy, poor and disadvantaged areas commercially viable. You just need to look at the tiny Pupil Premium (culled from within the schools budget) to understand how improbable this is.

Once “power is in hands of individuals” and he’s given “more people the right to take control of the budget for the service they receive”, what’s the next step? Cameron says he used to wonder why he wasn’t given control of the budget for his son’s healthcare. Perhaps because it would force almost impossible decisions on the NHS. How much is worth spending on each child? The Camerons would have been able to add their own money to make up a shortfall, but what if they were normal people? What if they chose a private hospital who put up their prices and suddenly Ivan would have been moved out because they hadn’t paid his bill? The NHS doesn’t (currently) make decisions based on price on an individual basis. Yes, price-related decisions must be made somewhere, but this is what the PCTs and Strategic Health Authorities are for. On the ground, you don’t have treatment stopped because of an outstanding bill. You aren’t thrown out of a hospital because you can’t pay.

The scope for disparity and resentment are enormous. Even as power for spending is handed to GPs, this is a serious concern. Now, the GP is on your side. In future, you may ask to be seen at a specific hospital, but be refused on the grounds of cost. And this refusal will come from the GP. In a properly competitive market, the logical progression is obvious. Fancy that lovely new private hospital? Just top up with your own money. It’s the end of a national system of healthcare and now it seems Cameron is extending the principle to every other facet of public service too.

The dangerous conclusion to this is a complete breakdown of the post-war social contract where people accepted that they pay a percentage of their income for the greater wellbeing of the nation as a whole. Why pay tax when you can simply hold onto the cash and buy your own services? Will people start to look resentfully at the amount being spent on one family’s healthcare and wonder why they are contributing when their loved ones remain healthy? What is you don’t like the local services on offer? Well, just “top-up” and buy your way to the front of the queue. The whole notion of national services unpinning our society comes under question. Why should someone who is paying for their own services also be paying for other people’s?

Very quickly we will find our country in a situation where if you can afford good services and you live in the right area, you will undoubtedly enjoy great provision. If you are unlucky enough not to be born wealthy you will have to get by on bargain basement services provided by the badly-motivated rump of the public sector. Think US healthcare.

If this seems like a faintly paranoid extrapolation, then look at the alternative. If every public service is competitively tendered, and price is a driving factor as “Big Government” budgets are squeezed, then the pressure to deregulate is enormous. Only within a very heavily (and centrally) regulated market can the service to everyone be kept at a specific level. How does the government drive new providers into the sector if it is going to keep a firm hand on the provision of services at a national level? Quite simply, it can’t, it won’t and doesn’t want to. The divisions this will create will make the current “postcode lottery” look like a minor inconvenience.

A defence of our national services requires two things – firstly, the loud and proud recognition of what they offer and what they have achieved. The NHS remains a beacon around the world, despite only recently being funded at a level close to the international average. It’s achieving record satisfaction ratings and while it’s not perfect, it does not discriminate on the basis of ability to pay. Alongside this is, perversely, the very notion of a “Big Society”. If we believe in society, then we accept that the better off contribute more, but they do so because they believe that our very Britishness is defined by fairness and a willingness to ensure every child has some basic services they can rely on, regardless of the circumstances of their birth. It comes from a recognition that everyone has a contribution to make to our country and that we share something as Britons which makes us happy and proud to contribute to the greater advancement of our nation.

A company is legally required to be amoral. This is not a criticism – its duty is to its shareholders. The state, on the other hand, has a responsibility to provide for people even when it may be messy, expensive and difficult. Remove this responsibility and all the relaunches of the “Big Society” in the world won’t keep the fabric of our nation together for much longer.

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The Long-Term Threat from “Govern Now, Think Later” Politics

For a party that’s had thirteen years to plan its next government (or nearer eighty, in the case of the Lib Dems), this Tory-led administration is incredibly short-sighted. It has rushed headlong into a mass of reorganisations and restructurings which look very badly planned and certainly lacking in democratic mandate. Take the School Sports Partnership, a way of allowing schools to co-operate in providing competitive and social sporting activities for their pupils. Scrap it, said Michael Gove, let Heads decide how to run sports. A stream of Tories lined up to praise this new approach – “free the schools!”, they cried in unison. However, people who actually understand school sports made it clear that without properly funded local organisation, school sport was under threat as Heads were forced to prioritise their spending at a time of limited resources. Which to scrap – the sports and games, of those extra computers or even a new teacher? It’s fairly obvious where the axe would fall.

So Gove relents and performs a u-turn which is indicative of this government’s short-sightedness. Hours of discussion about a new approach to school sports and then a hurried about-face. What a waste of time, effort and resources. A little more thought, a bit more planning and this could have been avoided. It’s vital that Labour portray this u-turn for what it is – poor government, hasty management and wasteful ineptitude.

If it was only school sports which suffered from this “govern first, think later” approach, we perhaps could excuse the coalition. They’re new, after all. However, across the board, the Tory government is rushing through decisions without proper consultation and often against the wishes of those impacted most.

In the NHS, a hugely costly reorganisation has the support of only a minority of GPs, who are now being handed £80bn of commissioning budget. The change will cost around £3bn at a time of falling revenue for the Health Service (ignore the “ring-fenced budget” claims – experts say the NHS needs 3% increases p.a. to simply stand still. It’s getting 0.1%). So why do it? The only groups clamouring for an overall like this are the private health companies who are lining up to provide the commissioning services GPs won’t be able to. Report after report has warned of the risks of the dramatic overhaul in the NHS, particularly when money is tight. But Cameron and Andrew Lansley don’t care. They’ve made a decision and evidence be damned. The difference between this and School Sports Partnerships is that while some kids might get fat with the one change, people might die under the other.

Of course the government don’t want people to die, but the stampede to be the most radical minister in an unelected government is leading to rash decisions which will unquestionably have serious effects on people’s lives. There is a lack of evidence that this is at the forefront of any minister’s mind as he or she lines up the next dramatic shake-up of public services.

Finally we come to the big one. The economy. It’s stalling as the effects of Labour’s stimulus packages wear off. Unemployment is rising and the private sector is failing miserably to fill the gap left by public sector lay-offs, precisely as most serious commentators expected. The only jobs being created are part-time, which provide no security to people and often mean families rely on benefits to achieve a living income. Everything is focused on the deficit. The price of Osborne and Cameron’s blinkered obsession with cutting the public sector to somehow restore economic balance is record-breaking youth and women’s unemployment and, perversely, negligible economic growth.

The short-termism is frightening. Even if the Tories manage to eliminate the deficit in an entirely arbitrary four-year period, what will the consequences of their approach be? We will have a generation of young people trapped in unemployment. A lack of stable communities as people are forced to move around hunting for work. Increasing resentment from those who lose out towards those who seem impervious to the deficit-cutting measures. In short, a much worse country to live in.

For anyone searching for an alternative, look to the post-war period. Despite a deficit and debt which puts the current one in the shade, various post-war administrations managed to invest in huge housing and infrastructure projects and of course, the NHS. Boldness brought great rewards. It’s time for further boldness now. Government should be looking to the horizon and to our future, rather than the present. Of course we must increase efficiency wherever possible and provide the absolute best value for money in our public services, but relentless cuts will hollow out the foundations on which they rely. Once lost, local services will never be recovered.

We should be investing in a genuine green investment bank, with the power to raise funds and independently invest in new technology. Instead we have a fund of £1bn, considered entirely useless by all serious commentators. This country has a proud tradition of pioneering innovation, but short-sightedness from the Treasury is standing in the way of a potentially lucrative new industrial sector. If we don’t seize the initiative, others countries will. We need an active and engaged industrial policy which supports industry, encourages businesses to build links with communities through specialist skills and secure employment and sooner rather than later, the Treasury coffers will feel the benefit.

As for our young people, much better to invest in genuine work placements (such as offered by the now-scrapped Future Jobs Fund) than simply hand out benefits then kick people for not finding jobs which don’t exist. When recovery final does come, how does the country benefit from underskilled and unemployed people, out of touch with work? Pay for jobs and training now and reap the benefits in the future.

The thinking required is joined up. Connect each stage of people’s lives to the next. Attacking Sure Start and removing the element of universality will remove the community cohesion these centres currently provide. I have seen first hand how bringing families from across the community together improves the local area as people recognise they have more in common than they imagined. Turn our schools into a market place of special interest groups and the “sharp-elbowed middle class” and watch as these divisions widen further. I would scrap charitable status for private schools, ease the administrative burden on Heads and work towards a truly comprehensive system where every student has a fair chance, not just those in a position to exploit their time and influence.

Support the Educational Maintenance Allowance which keeps pupils in education and allows them the best chance to achieve. Fund universities properly – we will never be the factory of the world, but we could be its R&D department – in culture, academia and humanities as well as engineering and science. Offer proper alternatives to university too. We should support apprenticeships and training schemes which provide paid employment to young people embarking on a career.

And finally, recognise the importance of a life outside work. Community stability, confidence in the next pay packet, a feeling that work and community are not always separate can rebuild society where too often, poorly paid and part-time jobs for multinational companies leave people feeling undervalued. We shouldn’t be demonising those unable to work, but creating an environment where work is available, properly paid and secure. Then we can tackle the tiny minority who are over reliant on the state.

This comes from a recognition that a divided society is an unhappy society. As bankers waltz on, bonuses in hand, ordinary workers are suffering. A paltry, watered-down bank levy does nothing to ease the sense of unfairness that the economic crisis created. The country cannot tolerate further division between the haves and have-nots. We can’t return to the way things were before. Labour gambled on an asset boom and a drip-down from the financial sector. While the revenue this created rescued our public services, the wider picture was ignored. But what this means is more government spending, not less. But this time, we need to spend to invest in the long-term. Only then will we see a rebalanced economy with stable, fulfilling jobs for everyone. This will bring the deficit down as genuine, secure growth returns to our country. It creates a future full of hope for our children, rather than debt and despair and it shows that while innovation is to be rewarded, greed never should be.

This government shows no signs of looking to the future, only a panicky rush to make changes before public will make it impossible. They may be building for their own futures, but for the rest of us, the outlook is bleak.

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Coalition of the Incompetent Will Regret its Haste

Imagine the scene. Labour has just about managed to form a government with the Lib Dems, after missing the widest electoral open goal in the history of modern politics. Despite the lack of a clear mandate, the party is paranoid about missing its chance and embarks on a series of upheavals, routinely labelled “the biggest shake-up since 1945”. Building enormous, wide-ranging policy blocks on a flimsy pillar of “it’s all the last lot’s fault”, the new government launches into the following initiatives in its first five months:

1) Cancels Building Schools for the Future, a vital source of income and employment for the private construction sector. In the process of this hurried cancellation, list after list of the schools affected is issued and reissued and within weeks, protesters are marching on Westminister, led by the government’s own MPs.

2) Uses parliamentary protocols usually reserved for emergency terror legislation to rush through a dramatic centralisation of power in education. New “Free Schools” can be established with no local authority control, no requirement to co-operate with existing schools and the ability to implicitly select pupils (through religion or catchment area). So popular are these new schools, accountable only to the Education Secretary, despite being paid for by the tax payer, that the grand total of 16 are approved.

3) Embarks upon the biggest ever top-down reorganisation of the NHS, despite explicitly stating that the new government would not embark on any top-down reorganisations of the NHS. The new policy, which opens the way to a private healthcare system, was not in any manifesto, will cost over £2bn to implement, is attacked by healthcare professionals, industry experts and patients groups as risky, expensive and badly thought-out.

4) Cites Ireland as a shining example of how to tackle a deficit, with savage spending cuts praised as “brave and necessary” by the IMF. This shining light is quickly extinguished, however, when the government notices that because of the excessive austerity measures, Ireland has fallen into a double-dip recession, its deficit remains high, thousands of people are suffering and those gods of the markets, the ratings agencies (“triple A” for a junk US mortgage CDO, anyone?) have downgraded Ireland’s government bonds because of the cuts and the complete lack of growth in the economy.

5) Announces at its annual conference that in order to tackle the deficit, Child Benefit for high earners is to be scrapped. In the haste to launch this policy, no-one considers the blindingly obvious problem of the considerable unfairness of hitting higher paid single earner families with a stay at home parent, versus two working parents on a much higher combined salary.

6) Following uproar amongst its own supporters, the government desperately tries to cover its tracks on Child Benefit by announcing a tax break for married couples, thus completely destroying the argument that the benefit cut was made in order to address the deficit. People search the conference hall for the fag packet on which the policy was devised and senior ministers admit they had no idea the policy was due to be announced.

7) The new PM apologises for not including the Child Benefit cut in its manifesto, but goes ahead and does it anyway. He cites something about new politics and parades his new baby in front of the cameras in a bid to ease the pressure on him and his government.

All this comes before the new government has got round to announcing the biggest cuts in public spending in living memory, while the economy remains desperately fragile and there are five people applying for every job. They have been repeatedly leaking rumours of cuts to the press though – £4bn of cuts to welfare here, a devastation of the armed forces there.

Now imagine, if you will, the press reaction to the Labour government’s actions. The newspapers are frothing at the mouth in anger. “We didn’t vote for this coalition of the incompetent!”, they cry. “Is this the worst start to a government in history?” questions The Times editorial. Sky News is running a clock estimating how long it will be before the government is forced to go back to the country. The Lib Dems are annihilated as a party, support slipping to a historic low.

Have you spotted those headlines (apart from the last one, that one’s true)? No? Funny that, isn’t it.

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More Politicans or Fewer? Government Must Make Up Its Mind

There are two very contradictory messages emanating from the government on the role of politicians in the provision of our services. On the one hand, they talk a great deal about localisation and handing power to locally-elected officials. This is true in particular in relation to the plans for the police, who are about to receive new, elected Commissioners with the power to hire and fire Chief Constables and set police priorities.

Ignoring for a moment the obvious dangers of politicising the police, this approach seems in complete contrast to the government’s policy on the NHS and schools. Free Schools are designed to give more power to professionals, and the government has expressly condemned the excessive interference (as it sees it) of politicians in education. “Let teachers take control” is the message. “Get the local authority out of the way”. The Free Schools policy hands any political control that does remain directly into the hands of the Secretary of State and completely bypasses local accountability. With the NHS too, the plans to shift the commissioning powers to GPs (private businesses effectively, with no local accountability), again removes any local politics from the process. The council loses any influence it previously had through liaison with the PCT. Again, this is taking away local democratic control over the health service.

The government cannot have it both ways. Either professionals like policemen, teachers and doctors are best placed to provide services, or they need elected politicians to ensure they are acting in our best interests. By offering an entirely inconsistent message on how best to run public services, the government is leaving itself open to charges of opportunism and confusion.

It would be cynical indeed to suggest that while it is easier to introduce private enterprise into the NHS and education, no-one would accept a private police force, and this has motivated the two approaches. A parallel approach in the police would mean allowing Chief Constables to take control of their budget and commission services from all manner of private providers. This, the government tells us, is a dangerous approach and Chief Constables must have their powers checked by “democracy” – see Boris Johnson’s Deputy’s comments in the Guardian today. What’s good for the NHS and schools geese, is not good for the police gander, and it’s right that we ask the government “why not?”.

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A Quick Musing on Choice

Prompted by an article in the Guardian by Aditya Chakraborrty, I decided to muse briefly on the notion of choice in public services being a panacea for improved provision. I don’t believe for a minute it is, and here’s why:

Choice, in itself, is probably a good thing, in the sense that I’d like to be able to choose to go to hospital within 20 miles, or send my daughter to a local school with decent results. I need to have some options available to me, but the issue of privatisation is not about introducing this kind of “equal” choice.

If you, hypothetically, introduce a private healthcare system which gives everyone a basic personal budget (national insurance, let’s say) and a range of hospitals to use, then a problem quickly arises. The companies owning the hospitals have the capacity to offer “value-added” services, so for a top-up fee, they provide shorter waiting times, private rooms, better food, more nursing attention. These patients quickly become the ones that deliver the profits to the company and so they become the focus. The people using only their national insurance end up with mediocre services at best, because they offer nothing to the hospital.

In fact, the hospital doesn’t really care if the non-top ups choose the hospital or not, because there is no profit in them. Inevitably, care for national insurance patients becomes poor, and maybe drives these people away, because they have a “choice” to go somewhere else. The problem is, all hospitals are the same and so regardless of the vast array of choice on offer to national insurance patients, the reality is that their service will suffer.

Put simply, you cannot claim that choice (effectively market dynamics) improves patient outcomes without looking at the supply side issues too. Choice alone will not drive up standards unless you heavily regulate the suppliers to ensure they offer a decent service to ordinary people.

This then automatically becomes a corruption of the very market forces you are relying on to improve standards (if providers can’t properly compete, why bother) and quickly results in a two-tier system. This is why in the provision of something absolutely essential (healthcare, education), market-driven choice as a driver of improved standards is a complete red herring.

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