Elections, democracy and making the best of it

On 18th April 2017 the Prime Minister indicated that she wished to call a general election.  Today it is likely that she will obtain the two-thirds parliamentary majority that she needs.  It doesn’t seem to matter what decision is taken, or why, but someone will always argue that it is wrong.  In this case Mrs May will be accused of opportunism, given the disarray in the Labour Party, which has agreed to an election even though its prospects are currently grim.  Of course when she became PM Mrs May was pilloried for not holding an immediate election to consolidate her position as an unelected (by the country) leader.  Now people are asking why she needs one; she has a parliamentary majority, after all.

It all comes down to Brexit.  As she put it, the country has decided on Brexit but at Westminster many people are intent on derailing the process.  A larger majority will dispose of any problems with votes.  But it will be interesting to see what the final result will be.  There are numerous imponderables.

  • The process of Brexit has begun, so UKIP is irrelevant; it has achieved its aim, and has no other policy to fall back on.  Where will their votes go in the Brexit-strong areas that were once Labour heartlands?
  • The Liberal Democrats remain Remainers (and remoaners).  Will they pick up votes from the Tories in their Remainer strongholds?
  • The prospect of the present Labour Party leadership making a fist of Brexit negotiations is so alarming that it cannot possibly happen.  Except everyone said that Trump was unelectable in the USA, and look what happened there
  • The Scottish Nationalists have made a great play about Scotland having voted to remain, and threatened another independence referendum so they can make their own way within Europe.  Except they have no money, as the oil revenues they trumpeted as the country’s resources have diminished substantially.  And so the Scots really want another referendum? Probably not.  So if the Scot Nats are remainers, and the Tories are the party of Brexit, where will Scottish votes go?

But the key to this is what democracy means.  The nation voted for Brexit.  OK, so bits of it did not, but in a democracy the minority must abide by the decision of the majority and not threaten to secede.  My household (of two) voted to remain, but we are not currently agitating to set up the Independent Republic of Norman House, Rye, but thinking about how to make Brexit work for the best (or the least bad).  The more divisions there are, the worse the nation’s negotiating position will be.

So my solutions to the questions above are as follows:

  • UKIP voters should vote Conservative so that Brexit will mean Brexit, to coin a phrase
  • People thinking of voting Lib Dem should not prejudice Brexit by undermining Tory MPs, but might consider the Lib Dems in Labour areas if they simply cannot countenance voting Tory
  • Trump at least managed to upset people and obviously was able enough to make lots of money.  It seems that Jeremy Corbyn is simply incompetent.  Also it is clear that he has a very short fuse.  Patience is a virtue, and simply losing one’s temper in public is not a good starting point for diplomacy.  So Labour voters should arrange his defenestration and if they can’t swallow their longstanding devotion to the Labour Party, they should not vote at all
  • I hesitate to advise my friends across the Scottish border how to vote, else the fish lady will come down on me like a ton of bricks.  But I think Scotland would be taking a huge risk in trying to leave the UK – a far greater risk than that of the UK leaving Europe.  So common sense dictates, remain or leave the EU, that they accept the majority decision and work to make it work, rather than bleat from the sidelines.  There are some very able politicians up there, and they would be better inside the tent pissing out than vice-versa.

It’s all rather exciting…

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Fixing the rotten NHS

I have been saying for years that the NHS is a “failed state”.  Reaction has ranged from agreement (among enlightened medics) through disinterest (among unenlightened medics) to dismay (among the public) and outright opposition (from politicians).  However its current position is increasingly recognised as unsustainable – or as I would prefer to be honest, bankrupt.  We have the absurd situation where the so-called commissioners of services, or CCGs for short, are so cash-strapped that they are trying to persuade GPs to ration prescriptions and referrals to secondary care.  On the other side the acute Trusts, or providers, are also “in deficit”.  They have tried over several years to apply temporary fixes.  They reduce spending by cutting staff; as a result, they fall foul of the monitoring body, the Care Quality Commission, which castigates them for inadequate staff numbers.  But they are equally castigated for overspending, whereupon the managers are put in the stocks, pelted with (figurative) rotten tomatoes by the public, and forced to resign if indeed they have not fallen on their swords already.  Meanwhile the government decides to harass the staff by forcing them into seven-day working, failing to assess or perhaps even realise that the costs of this are unsustainable.  It has already caused enough trouble by insisting on obedience to the European Working Time Directive.  As a result hospitals have been forced to employ more staff to cover shifts (simple maths – if you reduce individual hours worked by 20% you need 20% more staff to allow the same total hours).  Revenue costs have soared thanks to the building of new hospitals at unaffordable mortgage rates with almost endless repayment terms; this is known as PFI but is actually NHSSPM, or NHS Sub-Prime Mortgage Madness.

It is a miracle that up to now individual experience of the NHS has held up.  There are notable and well-publicised exceptions, often due, entirely predictably, to a lack of staffing and overstretching and stress of what staff there are.  But when over 80% of acute Trusts predict a year-end deficit, and the total deficit is predicated at £2bn per month it is time to say enough is enough.  We have spent almost the entire life of the NHS trying to fix it, and have failed.  It is time to stop papering over cracks – to stop funding shortfalls by budget transfers from capital to revenue, to stop secret bail-outs, to stop mergers that don’t work.    A business model where both the customer and the supplier are equally bust is unimaginable.  A model in which bankrupt people can continue to muddle on is mad. It is time to accept that the NHS is not a business but a service. And we must take a deep breath and start again.

This is not a time for political posturing either.  The NHS has been held up by the Labour Party as one of its crowning achievements.  Apart from the fact that it doesn’t currently work it is time for that Party to concede that it did not invent the NHS.  The principles were set down before the Second World War in a report commissioned by the British Medical Association and refined to an action plan by a civil servant during the war.  Only the accident of history that led to a Labour government in 1945 resulted in the NHS’s introduction under a Labour administration; had Churchill retained power, the Conservatives would have introduced it.  So that makes it all the more sensible that we forget who actually did what, and abandon the clearly sinking ship rather than bleat on about how wonderful it is, what a symbol of social equality it is etc etc.  Find me a single reorganisation of the NHS that has achieved its objectives (and there have been many reorganisations and objectives).  I cannot.  The fires in Rome have burned sometimes brightly and sometimes not, but fiddling has not put them out.

We cannot go on like this.

I have spent a professional lifetime scrutinising plans to save the NHS.  I have one overriding principle which seems essential to me, but appears to be overlooked by most.  It is this.  The first thing you do when someone comes up with a plan is to find one single thing that will scuttle it.  In science this is called the null hypothesis.  I remain amazed how many planners, many from medical backgrounds who have spent time doing research, do not do this.  As a result I have spent a parallel professional lifetime crying in the wilderness, pointing out why something will not work, watching while people implement the something and finally saying “I told you that wouldn’t work” when it doesn’t.  This was the fate of Cassandra, the prophetess of Greek mythology who always told the truth but to whom a curse was applied – that no-one would believe her.  Then there is a second non-scientific approach to change.  If you are trialling a new drug you do small pilot studies first – you do not launch the thing to the public in one fell swoop.  But there have been innumerable NHS initiatives that have been forced on services across the board.  So, when they fail, the whole organisation is affected rather than a small and remediable part.  Lastly there is what I call the panic plan.  Things are failing; organisers know that they will be held to (unreasonable) account and implement short-term “solutions” that don’t last and may make things worse.  Or they blame the doctors for being spendthrift, self-centred, lazy and greedy.  Which certainly makes things worse, because it antagonises the very people you need on side.

People have trumpeted the “need” to have good social service backup to keep people out of hospital, and have espoused the gospel of “Care in the Community”.  Sadly, however, many of these disciples have not analysed the costs of these alternatives.  Dispersed care is inefficient.  Peripatetic staff generate travel costs and more are needed to traipse about.  So while it may all be nice, it may not cost any less.  I am not going to state it costs more; I don’t know.  But common sense suggests it will.  So let’s not do it – at least until a pilot shows that money can really be saved.

Now I have been criticised when in Cassandra mode for being negative.   Why, people ask, when you think you can see clearly what is wrong, do you only tell people what is wrong and not put forward proposals of your own to put it right?

There are two answers.

  1. If no-one has come up with a way to put it right so far, what makes you think that my “solutions” will be any better than anyone else’s?
  2. While my negativity is evidence-based, my positive suggestions are not (because they haven’t been tried yet, or thought of yet, or if they have someone sensible has applied my null hypothesis rule and proved to their satisfaction, and sometimes mine, that my proposal won’t work).

But perhaps that isn’t a good enough reason not to try.  So I shall.

Back to the beginning.  We want these services.  We have this amount of money (forget commissioning and providing – all the money comes to both from government so any so-called deficit is an overall inadequacy of funding).  So what can we spend on what?

This is the so-called zero-based budgeting system.  We set out what we wish to provide and then calculate how much it will cost.  What we want includes GP services, acute hospital care, cold surgery, cancer treatment, mental health provision and all the other subgroups.  That provision requires facilities such as GP surgeries and hospitals and staff to run them.  We know (roughly) what the demand is, so can estimate throughput.  So we can calculate the costs of it.

So far so good.  If government allocates that amount of money then all is well.  If government can explain to the people that large parts of the money are not actually for healthcare (but for things such as staff pension costs) so much the better.  But suppose the money is not enough to do across the country what the country wants?

Four options.  The first is to increase the allocation so it is enough.  The second is to look for real and sustainable savings.  The third is to decide not to provide some of the things everybody wants – at least for nothing. The fourth is to generate income from non-NHS business.

No government will ever offer a bottomless purse, so we can rule out option 1.  On to option 2.  Real and sustainable savings are not achieved by cutting down on the one variable in NHS spending – the staff.  Buildings have fixed costs, but staff revenue represents 75% of the spend, so offers the “best” way to make savings, but cutting staff leads to mistakes and omissions, so you fall foul of the CQC as we have already seen so that plan falls down.  Real savings are made by cutting unnecessary drug prescriptions, by streamlining supplies, by abandoning high-cost vanity projects and by renegotiating debt.  All of these are possible; the last has already been implemented here and there; certainly no future PFI projects should be sanctioned – ever.  All you are doing is shifting the borrowing off one balance sheet to another, hidden one, usually at an interest rate that exceeds the rate at which the government could borrow for itself.  Some of the others could work but require a re-evaluation of the cost-benefit ratio.  For example, statin prescriptions are an enormous drain on resources for a small (indeed uncertain) gain in health.  Many patients are being given them for conditions they don’t have and may never get.  So abandon them!  Stop prescribing unnecessary antibiotics as well.  Others may think of others.

Actually, don’t forget commissioning and providing.  Abolish them.  All the system does is generate huge transactional costs at no benefit to any patient.  And while we are about it get rid of all the targets that require staff to spend vast tracts of their working week ticking boxes.

Option 3 has several possibilities. Again, some have already been taken up; varicose vein surgery is no longer offered on the NHS.  Others are controversial; expending huge sums on cancer drugs in cancers with poor prognoses; bariatric surgery for the obese (self-inflicted problem); not treating smokers with cardiac surgery unless they give up; abandoning arthroscopic surgery on knees; privatising sports injury services (also self-inflicted); cosmetic surgery; intensive care admissions for the seriously ill elderly; charges for outpatient appointments and A&E attendances; charges for inpatient hospital meals.  The list could go on but I imagine that some of these suggestions will have raised hackles already.  But, folk will say, what if it was you?  So what if it is?  If it came to it I would be happy with all of the above; I would also wish to be euthanased if I developed severe dementia, particularly if I became disinhibited and aggressive.

But – just because some of these discussions would be difficult does not mean we should not have them. Have you forgotten?  The NHS is bust!

Option 4 comes up against politicians (again).  Money is short, staff are stretched, so why even consider spending money on non-NHS sidelines, or what in NHS jargon is “non-core business”?  Quite simply, because some of them may be profitable and provide funds to plough back into patient care.  Look, for example, at redundant hospital buildings.  With closures and mergers there are lots about.  They are largely brownfield sites.  They get sold off.  Services such as power and drainage are already in.  The sites are developed, and developers make a giant profit.  So why not become the developer?  Or why not lease the site for a reasonable revenue income?  It has been done, but selling land is akin to selling the family silver; you might make a small gain but, in my experience, it is rapidly fed to the deficit.

Of course many will say (or whine) that doing some of these things will reduce quality.  Maybe.  I am sorry if it does, but if we cannot meet the quality standards we set ourselves – and currently the majority of NHS organisations cannot – then we need to re-examine the standards.  For what is the point of endlessly striving to achieve the impossible?

I could predict that the political response to this will be to say that some organisations do meet the standards, and if they can then so should every other.  But if you analyse why they meet them you find that most are very well funded.  If 20% are well-funded and 80% are not… you might as well say that it’s a disgrace that 80% are below average.  Come again?  That’s a statistical nonsense.  Think about it.

I remain uncertain that anyone is prepared to grasp the nettle and embark on a root and branch NHS demolition and resurrection (sorry – I had to get one more cliché in).  But if you are, phone me.

Election 2015: The Questions

  1. We keep being told past performance is no predictor of future performance, but the last government has gone a long way to rectifying the wreck left by the previous Labour administration, which spent vast sums of money the nation didn’t have. On the basis that leopards don’t change their spots, should I trust a government that got things half right or one that got it totally wrong?
  2. How can I trust a man who says his party is the only one that will save the NHS from its funding crisis when his party in government set up unaffordable PFI contracts that have caused much of the problem, and his party’s administration in Wales has made more cuts in the NHS than have occurred in any other part of the UK?
  3. How can I, a pensioner, take seriously a man who talks only of giving a better deal to working people, when he has barely done an honest day’s work in a proper job all his life?
  4. Why should I, in England with a population of 56 million people, be beholden to a Stalinist clique in Scotland that represents only 4 million and wants to be independent while holding the whip hand over its larger neighbour?
  5. If Scotland votes for independence in another referendum, should we not wave them a happy farewell, and watch them sink as the oil revenues fail to match their grandiose plans?
  6. If all men are equal (and women too, of course) why should they be taxed at different rates? This seems to be contrary to human rights.  After all on a flat income tax rate the rich pay more anyway.  It’s maths, stupid
  7. Being old enough to remember the revolting spectacle of gloating union leaders holding a government to ransom over tea and cakes in Downing Street, why should I wish to repeat the experience
  8. Why does business, big and small, panic at the prospect of a Labour government? Presumably not from some whim or the toss of a coin, but from genuine fear

I run my own finances, and do so in a responsible way.  As one political commentator put it, the Labour Party seems intent on maxing out on a platinum credit card with no idea of how it will pay off its debt. Responsible?  No.

So Lib Dems should vote Conservative if it will keep Labour out.  Conservatives should vote Lib Dem, or UKIP, if it will keep Labour out.  UKIPs should vote UKIP, or Conservative, if it will keep Labour out.  Tactical voting has never been more important.

Of course this is all a bad dream, and bears no resemblance to the real world… but that pledge stone – the Ed stone – looks awfully like a tombstone to me.