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Death might not be inevitable in Ed Miliband’s “leader speech”, but taxes might be?
Tobacco use is expected to kill around 5.4 million people worldwide a year.
It is undeniable that the state of the NHS is directly linked to the overall state of the economy. Austerity has posed a challenge to patient safety, though the official line is that “efficiency savings” have not impacted on safety in England. Nonetheless, it is a fact that unsafe levels of staffing have often been at the root of shortfalls in clinical safety.
The “Keogh review” could not have been a clearer example of this.
The public tend to be most concerned about the NHS if there is an identifiable event, such as Mid Staffs, or breaches of the four hour wait.
It is no big secret that Labour intend to make the NHS THE big issue of the general election campaign of 2015. This is despite the Conservatives’ electoral strategy Lynton Crosby not wishing to discuss the NHS.
But like a Marlboro cigarette, the issue of the link between Lynton Crosby, Philip Morris International Inc. (“Philip Morris”) and smoking policy has been a slow burn in the last year or so.
Labour has always wished to paint the picture that the Conservatives do not come with “clean hands” to the discussion of smoking and health.
There has always been the question: are the public aware of the financial problems facing the NHS? And, despite an universal consensus for low taxes, would they wish something to be done in the specific case of the NHS?
A new dawn for NHS campaigners was the relief that the media, who once a upon a time had been respected, were conflating “unsustainable” and “unaffordable” in their discussions of NHS funding. The NHS is, as they will tell you, should be comprehensive, universal, and free at the point of need. It is hard to know precisely where this confusion had arisen from. I remember vividly complaining about this on this SHA blog in October 2013.
In yesterday’s speech, the Shadow Chancellor Ed Balls made the direct link between income from taxes for the Government and the NHS.
“‘Next year, after just five years of David Cameron – with waiting times rising, fewer nurses and a crisis in A&E – we will have to save the NHS from the Tories once again,’ he said. ‘And we will do what it takes.’”.
Also in October 2013, the Local Government Association published a pamphlet entitled, “Changing behaviours in public health – to nudge or to shove?”.
And there is more than a cigarette paper between the two main political parties here on this ssue.
The current government has made exploring the potential of behavioural change a priority. In fact, the coalition agreement itself made direct reference to the issue, stating that the government would be “harnessing the insights from behavioural economics and social psychology”.
But likewise it has also clear that tools available to government include more draconian approaches as shown by the fact that consultations were carried out on plain packaging for cigarettes (a shove) and minimum pricing for alcohol (a smack). However, neither policy has subsequently been introduced.
I, over a year ago, wrote on this blog on the topic of changing behaviour in relation to smoking.
Ed Miliband has been banging on his “cost of living crisis” drum for some time. And, in fairness to him, it is an issue which resonates with the general public. For socialists, such as Owen Jones, the issue does particularly resonate as an example of how privatised companies with vested interests have protected their profits at the expense of their customers. They are able to do this due to markets, which have not failed from the perspective of the shareholder, but which have clearly failed from the perspective of the end user.
And a noteworthy consideration here is that such providers have been able to rely on robust demand, for example the need to drink water or to make a phone call. Likewise, certain luxury brands have not seen their profit margins dented by the global economic recession.
Indeed, on May 12 2009, it was reported that tobacco use would continue, possibly grow, during recession, according to experts at the time.
Death and taxes may be inevitable according to the famous Benjamin Franklin quote. But Lord Stewart Wood, advisor and friend to Ed Miliband, is known also to be petrified that Labour once again becomes known as THE “tax and spend” party. Whilst Labour might have been flirting with sexier and covert ways of working things to their advantage, such as “predistribution”, an epiphany lightbulb moment came when Labour realised it could get away with taxing entities rather than people, provided that it did not offend the neoliberal virtues of competition and enterprise.
In an economic downturn, products seen as giving comfort in the midst of stress tend to sell very well. In the U.S. and abroad, tobacco is no exception. That’s why taxing a commodity which does not become popular, and which could damage your health, is such an attractive political policy.
Just under a year ago, in October 2013, Ben Page as Chief Executive of Ipsos MORI presented a talk: “Public opinion: What price the NHS?”.
79% of the general public were reported as opining that the NHS should be protected from cuts (as opposed to other areas such as policing, benefits or schools).
88% of people agreed that the NHS “would face a severe funding problem in the future”.
Lack of resources and investment in the NHS is way above (42%) is way above other factors which could be posited to be “the biggest threat” to the NHS (including, for example, not enough doctors or nurses, or too much management).
Fast forward to now, and in a September 2014 report from “The Health Foundation”, entitled “More than money: closing the NHS quality gap”, the authors Richard Taunt, Alecia Lockwood and Natalie Berry considered that the NHS faces a significant financial challenge is well known and much discussed. This ‘financial gap’ has been projected to reach £30bn by 2021. This is due to the disparity between the pressures on the NHS and the projected resources available to it.
In the leader’s speech later today, Ed Miliband is ex[ected to put the nation’s health at the centre of a 10-year plan for Britain’s future on Tuesday, front loading the NHS with funding from a novel windfall tax on the profits of UK tobacco companies and the proceeds of a mansion tax on homes worth more than £2m.
A windfall tax normally has its critics because it’s considered to be a very short term measure that risks really damaging the relationship between government and big businesses.
But here is a windfall tax somewhat like no others – as the demand for cigarettes, despite the threat from e-cigarettes, is largely sustainable, and Labour if it is at any war with business is as at war with big businesses abusing markets.
In his final Labour party conference speech before next year’s general election, Miliband will tell sceptical voters he can bring the country back together and offer six ambitious goals, including changes to the NHS, designed to overcome “the greatest challenges of our age and transform the ethics of how Britain is run” over the next decade.
A mansion tax could raise £1.7bn, and had originally been earmarked by the shadow chancellor, Ed Balls, to fund a 10p starting rate of income tax, but that is now due to be funded by abolishing the marriage tax rate.
The poorest twenty per cent of households in Britain spend an average of £1,286 per year on ‘sin taxes’, including betting taxes, vehicle excise duty, air passenger duty, ‘green taxes’ and duty on tobacco, alcohol and motor fuels. In addition, they also spend £1,165 on VAT.
“Sin taxes” have generally been unwelcome by proponents of the free market, such as the Institute of Economic Affairs (“IEA”). In October 2013, the IEA published a report entitled, “Aggressively Regressive: The ‘sin taxes’ that make the poor poorer”.
In this report, the IEA made their disgust for ‘sin taxes’ clear.
It is said that, despite significantly lower rates of alcohol consumption and car ownership, the poorest income group spends twice as much on sin taxes and VAT than the wealthiest income group as a proportion of their income.
It is possible for the Conservative Party to mount an argument that tax is the single biggest source of expenditure for those who live in poverty, and indeed indirect taxes are a major cause of Britain’s cost of living crisis.
The average smoker from the poorest fifth of households spends between 18 and 22 per cent of their disposable income on cigarettes. The tax on these cigarettes consumes 15 to 17 per cent of their income.
And tobacco remains one of the world’s most profitable industries. Current data suggests that smoking is still a huge part of the global consumer landscape and that the habit is not going to die out anytime soon.
Philip Morris is currently the leading international tobacco company, with seven of the world’s top 15 international brands, including Marlboro, the number one cigarette brand worldwide. PMI’s products are sold in more than 180 markets.
In 2013, the company held an estimated 15.7% share of the total international cigarette market outside of the U.S., or 28.3% excluding the People’s Republic of China and the U.S.
On Sep 14th 2014, it was announced that the Board of Directors of Philip Morris on the NYSE/Euronext Paris PM), increased the company’s regular quarterly dividend by 6.4% to an annualized rate of $4.00 per share.
But cigarettes contain more than 4000 chemical compounds and at least 400 toxic substances.
Cardiovascular disease (disease of the heart or blood vessels) is the main cause of death due to smoking.
Smokers are more likely to get cancer than non-smokers. This is particularly true of lung cancer, throat cancer and mouth cancer, which rarely affect non-smokers. The link between smoking and lung cancer is clear. Ninety percent of lung cancer cases are due to smoking. If no-one smoked, lung cancer would be a rare diagnosis – only 0.5 per cent of people who’ve never touched a cigarette develop lung cancer.
Other types of cancer that are more common in smokers are bladder cancer, cancer of the oesophagus, cancer of the kidneys
cancer of the pancreas, and ervical cancer.
Chronic obstructive pulmonary disease is a collective term for a group of conditions that block airflow out of the lungs and make breathing more difficult.
So, in a weird way, smoking may come to be saviour of the NHS due to a perversion of market forces. It might be the latest brand of “left populism”, leaving Ed Miliband to want to have another puff. It is hard for the Conservatives to criticise without appearing to come down heavily on the side of tobacco companies such as Philip Morris, but Philip Morris are unlikely to forget this in a hurry if the Labour Party are responsible for denting their profits.
Public health was never a sexy campaigning issue for the Labour Party, despite the best efforts of some, with popular newspapers coming down heavily on the side of the consumer than the “interfering state”. But the whole concept of the ‘responsible state’ has become tarnished with neoliberal governments increasingly outsourcing state functions to companies embroiled in inefficient practices and allegations of fraud practices. A windfall tax on cigarettes, despite giving off an unattractive odour of Labour “going back to its taxing roots”, may be, however, just what the Doctor ordered at this particular time in the history of the service.
And, as all politicians know, you can’t please all of the people all of the time.
After today, Labour might be feeling like (a) whole (person) again.
Would nudging the corporate be more effective than taxing the individual in public health?
It’s hard to pinpoint how the resurgence of liberalism came about so recently.
It could’ve have been a genuine respect for letting people behave as they want free from barriers, in keeping with the neoliberal philosophy of unfettered markets.
The right wing have tended to try to conflate law with bulky ‘red tape’, though it’s interesting reading Hayek’s views on the law straight from the horse’s mouth.
As we approach steadily the UK election to be held on June 7th 2015, the usual criticism from the Conservatives will be that Labour likes to tax and spend your money.
Ed Miliband, with the able support of Livesey and Wood, though wish to have break from this cycle.
Hopefully their attempts will be more successful than Gordon Brown’s aspiration to release himself from ‘boom and bust’.
There is an alternative to taxing foods in individual consumer choices.
A disruptive way of looking at the issue would be to admit, but not necessary accept, that multinational corporates have a huge influence on customer behaviour.
And rather than taxing the individual the different approach is to ‘nudge’ the corporate. In English law, since the seminal case of Salomon v Salomon seen in the House of Lords, the corporate has been viewed as a ‘person’.
Various crimes can be levelled, to varying levels of success, at corporates, including theft, manslaughter and fraud.
It might therefore be possible to ‘nudge the corporate’, rather than taxing individuals.
The idea of a nudge comes from behavioural economics – a field dedicated to understanding why people and institutions make the decisions they do. It grew in the 1960s as scientific knowledge about the brain played a bigger role in psychology but it bubbled over with the publication of ‘Nudge’.
An American economist called Richard Thaler (already a don in behavioural economics) teamed up with Cass Sunstein, a legal scholar, to explain “choice architecture” – and, to defend its use. They argue that by presenting choices better, people make wiser decisions without losing their freedom of choice.
The last Labour administration was viewed by many as excessively authoritarian, e.g. the debacle over detention without trial. Since overplaying its hand, Labour has had moral difficulty in trying to persuade the public for the rôle of state intervention, though it has had some recent theoretical success over fixing colluded energy prices in oligopoly energy markets.
Thaler and Sunstein cite the example of a school cafeteria.
If the healthier food is placed at eye level and is easier to reach than the junk food, individuals’ behaviour might be altered – they might pick the fruit and veg even though they are still free to pick the chips.
‘Big’ has a lot of influence in the UK grocery markets.
Tesco control 30% of the UK grocery market, and have over 2,000 stores in the UK. In 2010 they made a profit of £3.4bn, yet they manage their corporate tax affairs successfully.
‘Fat taxes’ have taken various incarnations over the years, and the statistics cited seem plausible.
For example, a 20% tax on sugary drinks might possibly reduce the number of obese adults in the UK by 180,000.
The impact would be greatest in the under-30s, according to an Oxford and Reading university study.
But some groups say a tax is misguided and simplistic, and would not have an impact on older age groups who might benefit most from losing weight.
Doctors have called for a soft drinks tax to reduce sugar intake. Sugar-sweetened drinks, when taken regularly, have been shown to increase the risk of obesity, diabetes and tooth decay.
In thinking how to influence behaviour, it might be quite sensible to target efforts on the largest retailers here in the UK.
A report published in April 2011 – Right to Retail: Can Localism Save Britain’s Small Retailers? – argues that government must do more to rebalance the retail economy away from the “big four” supermarkets, which control nearly 80% of the country’s £150bn grocery market.
“Britain every year is less and less a nation of shopkeepers – assets and ownership are concentrating, finance has become the preserve of the City of London and high streets have converged as though by centralised design. The UK’s 8,151 supermarket outlets today account for 97% of total grocery sales, and 76% of groceries are sold by just the four biggest retailers,” the report said.
Rather than finding ways of taxing indirectly individual customers, a more sensible way might be way of finding incentives to encourage large corporates to behave a certain way on behalf of the end customer.
Corporates clearly care about tax.
Starbucks is to move its European head office from Amsterdam to London by the end of the year, following a row over corporate tax avoidance. The relocation will concentrate a “modest number of senior executives” in its London operation. The US coffee giant said its leaders would “better oversee the UK market” from the capital, adding that the UK was its largest European market. Last year, Starbucks paid £5m in corporation tax, its first such tax payment since 2009.
But tax is an explosive issue. Tax is seen as regressive and unfair as it lays the greatest burden on the least well off. Discriminatory taxation has thus far been ineffective in producing public health goals. Tax furthermore is unlikely to increase significantly government revenues.
But there are ways of rigging the tax system to encourage certain behaviours. And it might cause a redistribution of resources, judged as ‘fair’, to fulfil a genuine policy goal.
Supermarkets collect meticulous about their transactions anyway. The original criticism of ‘activity based costing’ (1992) cited in the discussion of the original papers of Cooper and Kaplan, which transpose to the criticism of ‘payment by results’, is that the amount of effort to collect data does not justify its subsequent analysis.
But supermarkets will know exactly how many bottles of full-sugar Coca they have sold. These data are easy to collect, in the same way that an individual has to collect meticulously information about his income tax claim.
A single fibre of asbestos can cause an aggressive cancer of the lung lining called mesothelioma. We all know the lengths which have been taken to ‘suppress’ the information about risks of tobacco for lung cancer. We have been witnessing a similar battle over sugar and obesity.
Unlike a single fibre of asbestos causing mesothelioma, knowing how much a certain lifestyle contributes to morbidity can be difficult. But that’s not to say there is no link. While intuitively people have railed against consumption taxes, or ear-marked taxation, the idea of guess-timating the amount of resources to treat people in the NHS from consumer decisions that they have made elsewhere is not totally ridiculous.
For example, greater obesity might lead to a greater prevalence of non-alcoholic fatty liver disease and cirrhosis.
Greater consumption of alcohol might lead to a greater prevalence of cirrhosis.
We already have a scheme which raises money for the NHS from business in the Road Traffic (NHS Charges) Act 1999. Each time there is an accident, a motor insurer is legally obliged to inform the NHS, which will determine if it is liable for any costs. The scheme is administered by the Compensation Recovery Unit. In 2001 the scheme was raising £100 million a year for the NHS.
You may have to pay Capital Gains Tax if you make a profit or gain when you dispose of all or part a business asset. Disposing of an asset might be selling it, giving it away or exchanging it. ‘Entrepreneurial relief’ is available for you as an individual if you are in business, for example as a sole trader or as a partner in a trading business, or hold shares in your personal trading company.
So an adjustment could be made for tax calculations for supermarket chains, and supermarkets will sell a lot of ‘healthy food’ could be given an appropriate tax relief.
But nudges don’t always work – especially when private companies have an interest in making sure consumer behaviour does not change.
Some claim that nudges can infantilise individuals by taking away their moral maturity. Others have also questioned their desirability, stating there is a fine line between persuasion and coercion.
And who’s to know what is healthy today suddenly doesn’t become unhealthy tomorrow. The relief rates for any tax adjustments could only be made according to evidence at any one time, and this evidence can and does change.
But the outcome of the discussion is not important as such. I’m more interested in how you might be able to ‘nudge the corporate’, increasingly with a lot of social and economic power, if there is a widespread unwillingness to tax an individual for his or her own choices.
Corporates might want to prove their sustainability credentials for all I know. But if the general public are still hugely fond of full sugar Coca Cola, corporates might be willing to sell it despite less tax relief. Market forces and all that.
A leading think tank publishes innovative suggestions to address the ‘funding gap’
Recent projections from the Nuffield Trust and NHS England suggest the funding gap could grow to £30 billion a year by 2021. The gap could be smaller if the economy as a whole expands faster than expected. But commissioners and providers cannot rely on this happening. In short, the sector faces its greatest financial challenge of recent times over the next eight years or so.
The Cassandra Society have long argued that their predictions of a crisis have been dismissed. The Society is alleged to have a number of hedge fund shareholders, and parliamentarians have never disclosed links to them when speaking on health issues in parliament. They published last year a now celebrated pamphlet, “Why Section 75 does not affect the state of the health economy”, echoing Lord Howe’s that the section 75 regulations did not change the law “one iota”.
The Cassandra Society confirm previous warnings that the NHS is unsustainable. A key proposal is that when people do the weekly shopping, whether online or otherwise, an individual could be nudged into giving a small contribution. The Cassandra Society argue that it would act like a form of “Gift Aid“, and does not threaten the principle of universality as it is completely voluntary. A number of sources have said that former Health civil servants, who also worked with Alan Milburn, welcomed the proposal.
Other think tanks have responded well to the proposal.
“For the first time ever, we would have an accountable mechanism of co-production”, said the policy officer of Compass.
“With One Nation, and whole person, we embrace the concept of ‘Unified Giving'”, commented the policy officer of the Fabian Society.
These proposals come at a time when Andy Burnham MP is about to go to Strasbourg to discuss the controversial TTIP free trade arrangements. The Labour Party, on the other hand, have refused to comment on the proposals.
“There is no intention to propose a ‘Gift Aid’ for the NHS. This is not and never has been Labour Policy.”
Should Lord Warner be finally expelled from the UK Labour Party?
It’s very important that people who bring the party into disrepute are expelled from the Labour Party. Imagine David Cameron’s delight if he were able to ask Ed Miliband how his plans to introduce a £10 fee were going? For squeaky clean Miliband this would be the worst thing to happen, after he has been agonising over policy for years, with some sort of climax at last expected in the National Policy Forum later this year. There isn’t much which unites the main political parties on the NHS, although critics of privatisation feel that they have a lot of neoliberal missions in common. However, one theme which they are all keen to be seen to be promoting is a NHS free at the point of need. David Nicholson, whose last week it is this week, has consistently said that he has thought that top up fees are likely to be kicked into the long grass.
Good people have been expelled from the Labour Party before. With Labour in opposition Bevan’s patience with the Labour leadership, which he saw as timid and unambitious, ceased. In the years running up to the Second World War, Bevan established a reputation as a left-wing rocket. He became the parliamentary scourge of both the Tory party and the Labour leadership. Bevan’s fierce attacks on the official Labour line even led to his expulsion from the party for most of 1939. More than sixty years later, in 2003, George Galloway was expelled from the Labour party after being found guilty of four of the five charges of bringing the party into disrepute. On the fifth charge – urging voters in Plymouth not to vote Labour – Mr Galloway was acquitted. You can argue until the cows come home whether pretending to be a cat with Rula Lenska on Big Brother was ‘a step too far’, but many people have had enough with Lord Warner’s antics. While he has the Labour whip, he is able to tour TV studios as some sort of quasi spokesperson of Labour, and give the impression that his ideas of jet-propelled privatisation have some sort of traction in the Miliband Labour Party. Miliband may feel sympathetic to Warner’s views for all I know, and that is why he doesn’t want to expel him. But if on the other hand he feels that expelling him is the best way to protect the founding principles of Labour, and universality of the NHS is a totemic one, Miliband may be forced to expel Warner at last.
There is something much more sinister at play here. The revolving door between government and the private consultancies gives ample opportunity for political influence by the consultancies private sector clients. There’s a whole host of people who come of jobs in government only to advise private equity and venture capital companies. The private sector clients include not just private healthcare firms and pharmaceutical companies, but telephone and IT companies, data collectors, private care home congolmerates, insurers and financial brokers. Expelling Warner from the Labour Party would serve to clip his wings in policy downstream. He is at risk of bringing Labour into disrepute over his NHS views in the future, because he “has form”.
In June 2006, during a Labour government (strictly speaking a Blair government elected under the name of Labour), it was reported that a secret plan to privatise an entire tier of the NHS in England was revealed prematurely when the Department of Health asked multinational firms to manage services worth up to £64bn. The department’s commercial directorate had placed an advertisement in the EU official journal inviting companies to begin “a competitive dialogue” about how they could take over the purchasing of healthcare for millions of NHS patients. At the time, a certain Lord Warner, then a health minister, defended the policy in a statement; he said he was withdrawing the advertisement to correct “a drafting error”, but insisted the contracting out of NHS management would go ahead. The advertisement asked firms to show how they could benefit patients if they took over responsibility for buying healthcare from NHS hospitals, private clinics and charities. The plan would give private firms responsibility for deciding which treatments and services would be made available to patients – and whether NHS or private hospitals would provide them. This is critical now as Andy Burnham seeks to establish Labour as the party which can ‘save the NHS’, despite appearing to support the private sector through ISTCs and PFI in the past.
At the time, Lord Warner said: “The government has no plans to privatise the NHS.” He added that the contract advertised in the official journal would give PCTs access to expert help to improve commissioning of services, without going through expensive and time-consuming local tenders. But this is an ongoing lie of many, who are either stupid or malicious. Fast forward a few years, and Lord Warner announced he would vote against the Labour party in a key vote in the House of Lords on proposed NHS regulations that the opposition says will allow companies to bid for almost all health services. And he did.
Despite a three-line whip in the House of Lords on a so-called fatal motion to kill the government’s controversial NHS regulations, the former health minister Norman Warner said he would vote with the Conservative and Liberal Democrat peers. The question must be: why wasn’t the whip withdrawn then? Sources close to Burnham described Warner’s intervention as “unhelpful” and pointed out that “he has a track record to consider”, noting that Warner was the only Labour peer not to vote against the government’s sweeping changes to the health system. Andy Burnham and Ed Miliband should consider having ‘crisis talks’ to expel Lord Warner from the party now.
And now, in his latest stunt, everyone should pay a £10-a-month fee to use the NHS. Lord Warner called for the levy to be paid before anyone could benefit from free treatment. Patients should also be charged £20 for every night they stay in hospital, he added. Absolutely no thought has been put into the administrative cost of this exercise. Lord Warner, who previously advised Tony Blair on health reform, said the NHS was ‘unaffordable’, ‘out-of-date’ and unable to meet the needs of the population. Simon Stevens who takes over from David Nicholson very imminently, who also in a previous life had advised the Blair administration of “New Labour” before joining the leadership of a multinational, will wish publicly to distance himself from such comments, especially if Labour withdraws the whip. In a report written for the Reform think-tank, he estimated that a monthly £10 charge for using the NHS would generate £2billion a year. But Reform have been lobbing these moves, designed to pave the way for a private insurance-based system, for years. Lord Warner has referred to the fact there needed to be a ‘tough conversation with the public’ about new ways of funding the Health Service, but the tough conversation which must be had now is by Ed Miliband and Andy Burnham to expel him from the Labour Party.
Should we more worried about a Trust in deficit or a deficit in trust?
“You can cut all the flowers but you cannot keep Spring from coming.”
? Pablo Neruda
For all the witch Hunts for looking for someone or something to blame, the number of constructive solutions has been unimpressive.
Some might say some of the media are part of the problem, not the solution, an anonymous friend said. But there are clearly ‘debates to be had’ about the news stories about the NHS which emerge into our popular press in short bursts.
Twitter trolls are people who land from nowhere, insult you and then disappear. They are the internet version of a random person sitting next to you on a crowded London bus, punching you in the face, and then getting off at the next stop.
And that’s the way we’re engaged in a debate about the NHS.
The French curiously have an opposite in their language to the word ‘inevitability’. It is called ‘evitability’. Part of the reason, I feel, that people feel so depressed is that they do not feel that they have actual control over the NHS policy in England from all the mainstream political parties.
Healthcare is expensive, but the NHS, when compared by percentage of GDP spent on health with countries with similar outcomes, is very good value for money. And yet it turns out that almost one in three NHS trusts in England is now forecasting they will end the financial year overspent, official figures show.
The term “self-fulfilling prophecy” was coined in 1948 by Robert Merton to describe “a false definition of the situation evoking a new behavior which makes the originally false conception come true”. He illustrated the concept with a run on a bank (a fictitious “parable”); his main application was to racial discrimination. The term has since entered social science and even everyday English, a rare feat for a sociological neologism.
So we are told that more NHS organisations are now in difficulty, compared with the same point last year. So what are we going to do about it?
There is no alternative (shortened as TINA) was a slogan often used by the Conservative British Prime Minister Margaret Thatcher. In economics, politics, and political economy, it has come to mean that “there is no alternative” to economic liberalism—that free markets, free trade, and capitalist globalisation are the best or the only way for modern societies to develop. The phrase may be traced to its emphatic use by the nineteenth-century classical liberal thinker Herbert Spencer.
But this lack of control, partly due to the quite manipulative way the debate tends to be framed by ‘influential’ thinktanks and media outlets, can lead to general dysphoria, perhaps apathy or depression. This is clearly relevant if members of the chattering political classes wish to seek out reasons why many potential voters feel disenfranchised.
A similar phenomenon is now happening with gusto, regarding NHS policy. That’s because we’re not offered any solutions, and feel powerless in controlling events.
Services have also been told to put aside £15bn in efficiency savings by 2015, in order to cushion themselves against further rises in demand.
This is clearly relevant to the ability of the NHS to hire new nurses. Many organisations are spending heavily on agency staff, with a 60 per cent rise in the total bill for locum doctors in the past three years, with doctors being paid up to £1,500 a shift.
Many of the worst problems are in London, where Barts Health NHS trust is predicting a deficit of £50m by the end of the financial year, and has drawn up plans to reduce the numbers of nursing staff on the wards.
Although the NHS has been protected from savings cuts, the demands from an ageing population and increasing costs of drugs mean services are struggling to meet demands on them, according to some ‘experts’.
The idea “reform is inevitable due to the ageing population” is immediately harpooned by issues when you look at the small print. For example, the cost savings from expensive cholinesterase inhibitors used to treat the symptoms of Alzheimer’s Disease to modest effect might be better put to use in guiding persons with inexpensive interventions to promote living well with dementia.
Professor John Lister, a health expert at Coventry University, said: “There are going to be more hospitals running into trouble due to debt problems.
“Some of the debts are astronomical. Repayments would have been tough enough in normal times but the recession and the need to cut £20billion from NHS spending has been the straw that broke the camel’s back.”
It’s a bit hit-or-miss whether you get a full account of events from such news items. For example, many articles couch the staffing of the NHS as a luxury, completely ignoring the issue that there is a minimum safe level of staffing on wards, whether Jeremy Hunt wishes to legislate for this or not.
Controversial private finance initiative which allowed more than 20 hospitals to borrow at high interest rates to secure new buildings have left some struggling to pay off the expensive mortgages, repayments can be up to five times the building costs.
The assumption that an ageing population makes the NHS unsustainable is not completely backed up by evidence. Indeed, increased life expectancy can increase the economic contribution of individuals, and need not be accompanied by increased morbidity – a concept known as ‘compression of morbidity’.
But should we more worried about a Trust in deficit or a deficit in trust?
David Cameron also promised to safeguard the NHS, lead the greenest government ever, create a fairer and more equal society, clamp down on tax evasion and clean up politics…
Regarding ‘clause 118′ giving special powers for a firestorm of NHS reconfigurations, Grahame Morris, Labour MP for Easington, recently commented,
“If the clause is agreed, we can expect tensions to be further exacerbated, and it should serve as a warning to us that the lack of meaningful consultation in the trust special administrator process leaves a huge democratic deficit and a black hole in accountability. ”
By the time the Health and Social Care Bill passed into law, becoming an Act, on 20th March 2012, it had garnered almost universal condemnation, with unprecedented agreement between the medical Royal Colleges, the British Medical Association, the Royal College of Nursing, the Royal College of Midwives, and many others – not forgetting nearly 180,000 signatures on the ‘Drop the Bill’ Government e?petition (the second?most signed petition on the site).
With the new construct of ‘accountability’ in the NHS, including for example Health and Wellbeing Boards and HealthWatch, it is hard to see how competitive tendering decisions can be challenged effectively without recourse to the law courts.
And now the Information Commissioner’s Office is concerned that the information provided to patients on care.data is not clear enough about how to opt out of the programme. The fiasco over care.data was possibly avoidable if the information leaflet had not been so badly prepared, and NHS England had given the appearance of seeking informed consent from individuals in the general public.
I think a Trust in deficit and a deficit in trust are all part of the same problem – a rational debate about the NHS being completely misrepresented in the media such that things which could be avoided are presented as inevitable.
I will inevitably buy a new car, but the longer I drive my current one only delays the inevitable. But allowing a storm to flood my car could speed up my search for a new car. In this case, God’s inevitability overruled my delay.
Likewise, from Cornwall to London, to Cardiff, Leeds and Northumberland, is it true that local authorities across England and Wales have been ignoring the Environment Agency’s protests and waving through developments on flood-prone land?
Sustainability: a hopelessly misused word in English health policy, popular for its misleading potential
For Twitter or Google, whose revenue potential is stratospheric, analysts have difficulty in defining how ‘sustainable‘ their business model is.
Turning the NHS into a Darwinian ‘survival of the fittest’ always implied that there were bound to be winners and losers. With recent legal decisions firmly deciding that NHS Foundation Trusts, as “enterprises”, cannot merge on purely economic competition law grounds is a profoundly significant decision, you can certainly say we are living in dangerous times.
And yet ‘sustainability’ is possibly the most misused word in English health policy. It means different things to different people. Its ambiguity means that it is highly popular, particularly for its midleading potential.
I was having dinner with a senior lawyer in Stockwell the other evening, and we both decided that, for many, the word had become synonymous with a meaning of ‘maintained’. We felt this usually led to a discussion of ‘we can’t go like this’, thus softening up the discussion to save money.
There is some method behind this madness, however. Rather than spreading money thinly around various hospitals, possibly there can be fewer hospitals with a ‘safe’ level of resources.
This argument clings onto the idea that the NHS funding is finite, and increasingly ‘unaffordable’. This of course is a perfectly rationale argument if you assume that the Government is incapable of producing economic growth. And for the last three years, the Government has taken us on a turbulent rollercoaster ride of GDP when the UK economy had been recovering in May 2010.
It is currently argued by some that the most successful healthcare organisations are those that can implement and sustain effective improvement initiatives leading to increased quality and patient experience at lower cost. Indeed, the NHS itself has produced a “Sustainability Model and Guide” to support health care leaders to do just that.
Next year, the “NHS Sustainability Day 2014” will feature tools and case studies with proven technologies, methods and projects that have yielded promising results. Technology is often cited as a potential source of the ballooning NHS budget, but the NHS simply has to learn how to order and use technology which is most appropriate for the needs of employees.
So why have the media and other professionals actually lost sight of the actual definition of ‘sustainability’? The politicians have an agenda to make the NHS more ‘affordable’, given the parties en masse wish to embrace ‘savings’ and not be THE parties of high taxation. This, however, means that politicians are being somewhat economical with the truth, and a responsible media here is critical.
Sustainability is the “capacity to endure“. In ecology the word describes how biological systems remain diverse and productive over time. Long-lived and healthy wetlands and forests are examples of sustainable biological systems. For humans, sustainability is the potential for long-term maintenance of well being, which has ecological, economic, political and cultural dimensions. It usually comes from an idea that you look after the people involved, and the environment.
Thee most widely quoted definition of sustainability, as a part of the concept sustainable development, is that of the Brundtland Commission of the United Nations. It was provided on March 20, 1987: “sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”
However the neoliberal approach taps into the oft-quoted saying, “The richer get richer; the poor get poorer.” Power always gets in the way of fairness in the game of sharing. With ‘finite resources’, unfortunately there will always be winners and losers. For parties which claim to offer ‘comprehensive, free-at-the-point-of-need’ NHS, clearly it is impossible to square this particular circle.
Irrespective of the ageing population, which is a sensitive argument as it implies that aged individuals are a ‘burden’ on the rest of society despite the value that they have generated over their lifetime, “demand” appears to be fundamentally outstripping “supply”.
According to the 2008 revision of the official United Nations population estimates and projections, the world population is projected to reach 7 billion early in 2012, up from the current 6.9 billion (May 2009), to exceed 9 billion people by 2050.
In 2009, McKinsey says the NHS can save an initial £6bn-£9.2bn a year over the next three years through “technical efficiencies”. This produces a cumulative three year saving close to the £20bn NHS chief executive David Nicholson has been talking about since his annual report in May.
But the McKinsey report went further, suggesting the NHS could save a further £10.7bn a year on top by improving quality and shifting care to the most cost effective settings. Sir David Nicholson, as in effect the NHS’ CEO, grabbed the bull by the horns. Unfortunately, some Foundation Trusts have used ‘efficiency savings’ to run skeleton staff who are always a number of patients ‘behind’ in the Medical Admissions Unit or A&E.
According to a previous report from the National Audit Office, in 2011-12 there was a large gap between the strongest and weakest NHS organisations. The difference was particularly marked in London. At the time, there were 10 NHS trusts, 21 NHS foundation trusts, and three Primary Care Trusts (PCTs) reported a combined deficit of £356 million. The NAO estimated, based on their census of PCTs, that without direct financial support, a further 15 NHS trusts and seven PCTs would have reported deficits.
Sustainability is an issue in the Lewisham case (judgment here). Judge Silber remarked that on occasions it has proven impossible to improve speedily the performance of a failing NHS organisation sufficiently to secure an adequate quality of care for its patients within sustainable resources. For that reason, an exceptional bespoke procedure was introduced to deal with situations which arise,
At paragraph 3, Silber describes it as follows:
“in the words of a senior official of the Department of Health, Dr. Shaleel Kesevan, “where very occasionally it proves impossible to improve the performance of an NHS organisation sufficiently to secure adequate quality of care within sustainable resources”. This regime is entitled the “Unsustainable Providers Regime” (“the UPR”), which as its name shows was intended to deal with failing NHS organisations.”
It is clear then that some of the basic, actual, definition of ‘sustainability’ has got lost in translation. This is unfortunate given that the primary purpose of politicians, of all shades, should not to be to mislead the general public whether intentionally or unintentionally.
Above all, the NHS should be in touch with its wider environment. This does mean that the NHS should look to the forests or trees for inspirations. It means that when 50,000 protest lawfully in Manchester, there is no news blackout and people are genuinely concerned about why people are so upset.
It means listening to local residents in Lewisham. It does not mean instinctively using hardworking taxpayers’ money to appeal against a decision from the High Court in the Court of Appeal.
It also means listening to the views of nurses when they’re in a job, and listening meaningfully to them if you need to sack them. It is not as if the NHS is actually short of work to do, which is why some find it objectionable that there are staff cuts with ever-increasing demand.
That is the true meaning of ‘sustainable’. Unfortunately, the current Government is producing amendments to the insolvency regime to make neoliberal closures easier for the State, quicker than you can say, “Earl Howe”.
The NHS might be truly ‘sustainable’ if you pay especial attention to hardworking hedgies, as per the Royal Mail privatisation. To take the neoliberalisation of the NHS to the limit, you could sell it off as an initial public offering (or flotation). But is this another difficult choice the public are being shielded from?
The word “sustainable” has been bastardised. It has been taken away from its true meaning from the macroeconomics. Such abuse of language is symptomatic of an abuse of political power.
Will Mr Brown pledge to real-terms increases in the NHS? I’ve done it. So will he?
Will Mr Brown pledge to real-terms increases in the NHS? I’ve done it. So will he? David Cameron April 2010
Cameron to take on Labour over NHS - October 2006
The big NHS underspend: Andy Burnham writes to Jeremy Hunt
This is the rather dramatic start of the HSJ article yesterday:
At a time of a huge financial squeeze being put on hospitals and when treatments of all sorts are being cut or delayed (or “rationed”), it turns out that the Department of Health – the unit in charge of the NHS – has a huge surplus that it is returning to the Treasury.
Andy Burnham MP has written to Jeremy Hunt MP as follows.
Dear Jeremy
NHS Budget underspend
Figures published today by the NHS Information Centre show that in December 2012 there were 4,887 fewer nurses working in the NHS than in May 2010. This followed the Care Quality Commission Care Update, published earlier this month, which warned that 11% of hospital services inspected were failing to meet the standard on adequate staffing levels.
You can therefore imagine my surprise when reading figures published in the detail of the Budget document yesterday that show the Department of Health is expected to underspend against its 2012-13 expenditure limit by £2.2bn.
Furthermore, the table on page 70 of the Budget document appears to show that none of this has been carried forward to be used in subsequent financial years as part of the Budget Exchange programme.
At a time when the NHS is facing its biggest financial challenge, when almost 5,000 nursing posts have been lost since the general election, and when one in ten hospitals are understaffed, I find it staggering that £2.2bn of the NHS budget is to be returned to the Treasury.
It would be helpful if you could therefore answer a number of important questions.
1. Were you aware of the £2.2bn underspend before yesterday and did you authorise the decision not make any use of the Budget Exchange programme? Or were you overruled by the Treasury?
2. If so, when did you make your decision?
3. Can you confirm that this means the Department’s underspend for 2012-13 would be 2%, higher than the 1.5% figure that your Department says is consistent with “prudent financial management”?
4. Do you accept the recent findings of the Care Quality Commission that one in ten hospitals are failing to meet the CQC standard on adequate staffing levels? Did you consider this when making your decision?
5. Why did you not make use of this underspend to prevent job losses and ensure all hospitals have adequate staffing levels?
6. Yesterday, a Department of Health spokeswoman told the Health Service Journal that the NHS underspend would “still be available for NHS organisations to ensure high quality, sustainable health services are delivered to patients now and in the future”. Can you confirm that this will not be the case, as none of the £2.2bn underspend has been carried forward for future use?
I look forward to your response.
Best wishes
Rt Hon Andy Burnham
The plot thickens…
efficiency savings
