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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.
Many posts like this have originally appeared on the blog of the ‘Socialist Health Association’. For a biography of the author (Shibley), please go here.
Shibley’s CV is here.
How one lie led to another – we'll be clearing up the economic mess Clegg left
Nick Clegg falsified the story, thereby rewriting history. He then got himself into Government, and then ruined the country.
It is easy to see the magnitude of Clegg’s failure when you refer back to the Budget debate for 24 March 2010, prior to the 2010 General Election (as recorded in Hansard). The context is some quibbling over the growth figures in David Cameron’s response:
This is in fact what has happened since May 2010. In April 2012, new figures revealed that Britain had plunged into the first double-dip recession since 1975 and is enduring its longest economic slump for a century. This was in fact the first double dip for 37 years and a nightmare scenario for Chancellor George Osborne, who predicted a rapid return to growth when he embarked on his austerity programme, and Mr Cameron, who had previously declared Britain ‘out of the danger zone’.
Source: tradingeconomics.com
It suited Nick Clegg and Vince Cable to defer as much blame onto Gordon Brown for the recession, rather than to blame global factors.
Indeed, Cable, Clegg and Osborne have been wishing for the Eurozone to implode much more than it has, in the same way that they have always hoped for the GDP figures to be ‘revised upwards’. Northern Rock, indeed in 2007, was one of many banks throughout the world to take on risky investments. Many of the assets that these banks had on their balance sheets started to lose their value (like ‘loans gone bad’ or securities derived from mortgages and other loans). The Bank of England became the last resort for the British banks as liquidity froze throughout the global market due to a lack of confidence. The global crash was predicted by Roubini (2010) who said: ‘As homeowners defaulted on their mortgages, the entire global financial system would shudder to a halt as trillions of dollars’ worth of mortgage-backed securities started to unravel’ but the United States and the United Kingdom refused to acknowledge sub-prime mortgages as a threat to the economy’ (N. Roubini and S. Mihm (2010), Crisis Economics: A crash course in the future of finance, Allen Lane, United Kingdom, 2010, p.15). At the time, Nick Clegg criticised the Labour government for not having done anything about getting banks to lend:
However, Clegg is being utterly disingenious about the UK government’s ability to lend money given the overall international climate. Firstly, banks are affected by Basel Capital rules that financiers keep complaining about; subtle reforms on, say, liquidity coverage ratios are also “biting hard”. This overall, it is argued, makes banks far more conservative about lending money and fearful about how they manage their balance sheets. Gillian Tett in the Financial Times in October 2011 gave a very elegant overview of the situation, as it was then. Nick Clegg appears now to have some sort of weird amnesia what had caused the deficit to balloon, but he was very clear about the bail-out at that time.
Clearly then, the “deficit” story is the one to base the entire credibility of the raison-d’être of the current Coalition, but the facts clearly state that prior to the global financial crash the deficit being run by Labour was comparable to that run by Norman Lamont and Ken Clarke, as clearly shown here:
Therefore, it is perfectly clear that David Cameron and Nick Clegg have hugely misled the UK on the situation it is currently in, and ‘one lie leads to another’ unfortunately. The Conservatives, Andrew Neil and the Spectator, have been fixated on whether or not Ed Balls knew there was a structural deficit in 2008, whereas English law fundamentally relies on there being a presumption of innocence. Ed Balls is convinced that he, and the Bank of England, did not realise there was a structural deficit in 2008, and indeed the more relevant situation is what to do now. For example, in its twice-yearly fiscal monitor, the IMF said that for countries including the UK: “If growth should fall significantly below current projections, countries with room for manoeuvre should smooth their planned adjustment over 2013 and beyond.” This represents conditional support for Mr Osborne’s deficit reduction plan so long as growth does not disappoint again. Indeed, Andrew Neil and colleagues then curiously perseverate on how much Ed Balls knew then, whilst being completely obvious to any of the arguments about why the GDP remains stagnant now, why the banks fail to lend, and how a failure in securitised mortgages caused a global recession.
“To summarise, both governments presided over a fiscal strengthening in their first three years in office followed by a weakening over the following eight. But we should note that Labour has used more of its borrowing to finance capital investment rather than current spending than the Conservatives did. Under the Conservatives, the structural budget deficit continued to deteriorate until year 14 (1992–93). It remains to be seen when it will reach its trough under Labour.”
This rather begs the question: what was Mervyn King actually worried about in 2008? King in a speech at a dinner hosted by the IoD South West and the CBI at the Ashton Gate Stadium, Bristol in 2008 provided the following:
“The low level of national saving is apparent from the current account deficit – our new net borrowing from overseas – which in the third quarter of last year was, relative to GDP, the biggest in the past fifty years and the largest in the G7. It is possible to run a current account deficit for a considerable period. Australia, for example, has done so in every year since 1974. But our own position is becoming more difficult. For some years we have been able to finance current account deficits by borrowing, often through banks, at unusually low interest rates on world capital markets.”
In other words, he appeared to be confident about our “paying off our deficit” due to “low interest rates on world capital markets”. Of course, one lie leads to another, and we’ll now be clearing up the mess that Clegg left in 2015. Clegg will probably defend successfully his seat in 2015, but, as the Liberal Democrat Party implodes, there’ll be nothing left for him to defend, and he will better off in the House of Lords or Europe. Meanwhile, it is quite likely that some sort of austerity plan will be mid-way until 2018, and the disappearance of our AAA coveted credit rating (as warned by Fitch recently) will have been a direct pack of lies we have been fed for the last few years.
My predictions in @LabourList in January 2011 bore fruit today
I think it’s good to have a ‘cards on the table’ approach. On January 2nd, 2011, I wrote the following in LabourList:
Is government debt like a credit card debt?
David Cameron and Nick Clegg have consistently likened government debt to credit card debt (like paying for your weekly groceries). This is a plausible common-sense approach based on the electorate’s instinct for belt-tightening, and the hardships they will be experiencing in difficult times. The analogy is clearly weak, but analysis of that is way beyond the scope of this article. Given that the public appear to like this comparison, it might be useful to explain also what might go wrong in such terms. The biggest threat for the UK in 2011 is that unemployment goes up and therefore benefit payments go up, while tax receipts go down. This would be like credit card bills beginning to “flood in”, while you are unable to deposit any money into your bank account.
Interestingly, this is what was written about midday today in an article entitled “UK’s budget deficit doubled in February”:
The UK’s budget deficit almost doubled in February due to a drop in tax receipts and increased spending. According to the Office for National Statistics (ONS), public sector net borrowing, excluding public sector interventions, hit a record for the month of February. It jumped to 15.183 billion pounds last month from 8.875 billion pounds in February 2011. The pound fell immediately after this announcement early in the morning. The ONS said that the increased borrowing was driven by a 2.7 percent drop in tax receipts on the year, while government spending climbed 8 percent. Income tax alone dropped 12.4 percent on the year in February, while benefit payments rose by 11.2 percent. This announcement leaves Chancellor of the Exchequer George Osborne little room to meet his full-year goal as he prepares to announce the UK’s annual budget later today.
Indeed, what I even alluded to at the beginning of January 2011 emerged as a theme in an influential blog today in the Telegraph:
Then there was the vague promise to find another £10bn annually in welfare cuts by the end of the parliament. I couldn’t get my head around that one. Is this in the deficit reduction programme or not? The Chancellor will probably get away with it as far as the markets and the credit rating agencies are concerned, but the big picture is that Plan A no longer really exists. Much lower growth than expected and the political compromises of Coalition have blown it off course.
Well, I hate to tell you, as a Keynesian, but … I told you so! My other prediction is in the absence of a full Eurozone crisis I don’t expect this budget deficit to be paid off by 2015, and Labour is going to have ‘put its cards on the table’ as to whether it will maintain the cuts agenda, and how.
