A Legless Healthcare Announcement

The PM’s £20bn. healthcare announcement may remind you of Dudley Moore auditioning for the role of Tarzan even though he had “one leg too few”.  Back in January, the Government made a big deal of adding “Social Care” to the name of the Department even though it had already had that role for six years.  The announcement reflected the widely held view that the NHS and adult social care should be seen together and, indeed, the NHS could only work if social care was adequately funded and integrated with it.

Last year the Department of Health (DHSC) announced it would free up the 5% of beds occupied by people well enough to move to social care. But discharging patients earlier is only part of the potential savings from integration. With better funding and management of adult social care, fewer older people would need to visit their doctors or be admitted to hospital in the first place. Naturally the Government did not provide any money to achieve those aims and they were not realised. The funding adult care green paper, due these past two years, is still not expected for some months.  Insiders predict it will be a damp squib. On Monday, The Independent put it this way “Theresa May to warn social care must wait until 2020 for extra funds, despite pledging £20bn for NHS.”

Since 2009/10 the NHS has figured out that their own funding of adult social care actually saves money for the NHS. In 2015/6 they provided nearly £2bn and this year it is probably close to £4bn. No one in the DHSC, it seems, has worked out the optimal diversion of resources between the NHS and adult social care. As a starter, it could redirect the £760M it spends on unnecessary quangos. Don’t hold your breath on that. The DHSC does not spend any money on adult social care at all: the funding mostly comes from local authorities with a declining contribution from the Ministry of Housing, Communities and Local Government. This has been topped up with three extra contributions:

  • “A Social Care Precept, under which local authorities are able to increase council tax levels by up to 2% or 3% (above the referendum threshold)…..
  • An improved Better Care Fund –to include additional social care funds of around £4.4 billion between 2017/18 and 2019/20
  • An Adult Social Care Support Grant which will provide £240 million to local authorities in 2017/18 and £150 million in 2018/19.”

How the Sajid Javid, then Secretary of State, determined, in February 2018, that £150M would fix the £2.3bn. funding gap passeth all understanding.

Unsurprisingly, omitting social care from the new health funding has been greeted with horror by local authorities: “Glen Garrod, president of the Association of Directors of Adult Social Services (ADASS), said the Government’s plan to increase funding for the NHS while leaving out social care was similar to ‘pouring water down a sink with no plug in.”

Health care in England should be seen as a whole, a trinity of Health England (prevention), NHS (curing) and social services (caring). The DHSC has responsibility for, and funds, the first two but the third escapes their consideration.  The whole structure, with its commissions and quangos, trusts and advisers, managers and independent primary practices, is such a mess we need a non-partisan convention or commission to make sense of it and then what the optimal spending mix should be. 

Lord Darzi is a surgeon and former (Labour) Health Minister and has, with Lord Prior, his Tory equivalent, been demanding an extra £50bn. which turns out to be 3.5% p.a. - not far from the government’s £20bn, which is actually 3.4% p.a.  Don’t ask me to explain politicians’ arithmetic. Although he preaches integration, Lord Darzi’s his arithmetic does not practice it: his £50bn is just for the NHS. He does, however, agree that NHS reform should come before the necessary funding is evaluated, the right leg of healthcare provision, the NHS, does need more money and should have it.  But this £20bn. announcement is one leg too few.  As Cook put it “I have nothing against your right leg but then, neither have you.”

This is bananas - incorrect uses of the word "however"

The Guardian brings us some good news. A small - and British, for what little that matters - company is getting somewhere with solving one of the world's problems. That specific thing we hope gets solved being bananas.

The world's commercial crop is, pretty much exclusively, one cultivar, the Cavendish. There are hundreds of others out there, but that just the one is the commercial industry. More than just a cultivar, they're all clones. Thus any disease that can affect the one plant (an herb apparently, not a tree) can and will affect all globally. As is currently happening.

We know roughly what to do about this as we've done it before, when the Cavendish replaced the earlier clone Gros Michel suffering the same problem.

So, a problem, someone's working to solve it, and ain't that great? At which point we are told:

However, they face competition from other research companies and academic institutions.

However's not the right word there. We face uncertainty - we simply do not know what is the right, in detail, response. Perhaps it is to move to another cultivar. Maybe it's GMO to make the Cavendish resistant. Maybe it's to abandon banana cultivation. Well?

Which is exactly why we use markets as our experimentation machine to find out. Lots of people try in lots of different ways and we use that calculator of the entire economy to work out which is the best answer.

The correct phrasing therefore is "Huzzah, they face competition from other research companies and academic institutions."

There's a reason to have private ownership of something like Hastings Pier - to cover the losses

The "community organisers" who lost out in their bid to purchase the bankrupt Hastings Pier are complaining. Yet there's a good reason to have such things in private hands. Shareholders, private such, don't just collect the profits when there are any, they also pay the losses when there are such:

Campaigners fighting to save Hastings pier for the community are “devastated and furious” over its sale to a businessman for a fraction of what it cost to rebuild.

The Eastbourne hotelier Sheikh Abid Gulzar was reported to have paid £50,000 for the pier, which was rebuilt with £12.4m of lottery money but went into administration last November.

Well, yes, but why did it go into administration?

Partly funded by donations from 3,000 local residents, it was subsequently hailed as “the people’s pier” by Ben Derbyshire, the Riba president, and credited with “evolving the idea of what architecture is and what architects should do”.

But now Hastings Pier Charity, which employs 44 people, has admitted that it has been unable to agree a new three-year business plan with its major stakeholders — the Heritage Lottery Fund, which provided £11.4 million for its restoration, Hastings borough council and East Sussex county council.

The organisation, which became the first community benefit society in 2013, had hoped to raise £800,000 to become self-funding but entered insolvency when it fell short of its target.

Nonetheless, it said it felt it would be wrong to ask its 3,000 community shareholders, each of whom donated £100 to get the project started, for more money to meet the pier’s operating costs.

Ah, so they've already tried that community route and despite massive subsidy it failed. Which is where this private shareholder thing comes in. We can, and should, assume that more capital will be put in. For without it it will go bust again. And with private shareholders there is at least the possibility of their stumping up more such capital, something which a community organisation clearly has great difficulty in doing.

The importance of those shareholders being revealed once again. Sure, they take the profits, but they also provide the capital to cover the losses, don't they? 

Wood and trees - Tesco the best, Waitrose the worst for food waste, apparently

An interesting little insight into how some think the world should be run. The underlying subject is food waste in the supermarket supply and retail chain. An odd thing to be worrying about really, as the very existence of that supermarket supply and retail chain is what reduces food waste to minimal levels in the first place. Any reading of FAO and the like reports reveals that it is their absence which leads to 50% and about of food rotting between field and fork. Their existence leads to  some being tossed from the shelves, to be sure, also to odd bags of salad rotting at the back of our fridges. But the efficient food collection and distribution systems which are supermarkets is the very thing which reduces food waste.

But, you know, far too many people with too much time on their hands:

Another day, another supermarket-bashing report – even if this latest one is slightly unexpected. This time it’s aiming at the upright, conscientious, middle-class shoppers’ favourite. But now Waitrose has been criticised by the campaign group, Feedback Global, for being the worst performer out of 10 UK supermarket chains at tackling food waste.

According to Feedback Global’s findings, Waitrose provides no public data on food waste. It redistributes a small quantity of food compared with other retailers, has done limited work with suppliers to reduce food waste, and has no programme to send permissible food surplus to serve as animal feed. This is in striking contrast to Tesco – the supermarket all right-thinking people like me are supposed to hate. Tesco was the first group to produce third-party audited food-waste data, and in 2017, according to the report, increased its food surplus distribution network by 40% on the previous year, donating 7,975 tonnes of food to people in need.

The full report is here.

The problem with this is that the report is noting how well the varied supermarkets do the form filling and box ticking. Where's the report on how near out of date food is given away to the homeless, do we have that document detailing stuff sent off for animal feed? What the report doesn't do is provide any information at all on who is throwing how much food away.

For example, imagine for a moment. A supermarket chain has an aggressive discounting policy. Anything getting near to the end of shelf life, close to sell by date, is discounted so much that crowds of the impecunious storm the stores and cart it all away. The chain has no food waste at all in fact. They therefore don't fill in all the forms as there's nothing for them to form fill about. By the standards used in this report that supermarket chain would be bottom of the listing. 

No food waste at all, no concomitant documentation about disposal of food waste, bad marks.

We do not, not in the slightest, claim that Waitrose emits no such waste. We haven't a clue whether it does or not in fact. But a measurement system which cannot even tell how much food waste there is isn't going to be all that useful in measuring food waste now, is it? 

As up at the top the issue of how much emanates from the supermarket chains we think entirely unimportant, as it's their very existence which reduces the original problem of food being wasted. But if we do want to worry about it let's do so by studying reality, shall we, not the paperwork?

Perhaps it should solve the problem, but does it?

We can all think up solutions to varied societal problems, methods of achieving desires. Some of them are even based upon reasonable logic. For example, if the gender pay gap is the creation of gender different reactions to the arrival of children, will insisting upon gender neutral responses lea to the eradication of the gap? Seems a reasonable enough insistence to be honest.

It's also largely our own view - men and women tend, note, tend - to react differently to the arrival of the little ones and the intersection with that working world out there. That's what causes that gender pay gap. If that reaction were entirely gender neutral - if, for example, 50% of fathers became primary child carer - then we do think that the pay gap would disappear.

That doesn't though mean that mandatory paternal leave is going to do away with that gap

In the family of Canada’s provinces and territories, Quebec has long been the noisy, rebellious child. In 2006, it divorced itself from the country’s complex and lacklustre parental leave programme. The province created its own system, the Quebec Parental Insurance Plan (QPIP), a model influenced by Scandinavian countries and with the aim of improving gender equality.

Well paid paternity leave which can only be taken by the bloke. This has more than a small resemblance to things being proposed here, doesn't it?  But the important question isn't whether the logic seems reasonable, it's whether it actually works. You know, that testing of a hypothesis against reality?

Among the provinces, P.E.I. is the standout performer. The province gets a "B," but with a wage gap of 10.7 per cent it places fourth overall, after Belgium (3.3), Denmark (6.3), and Norway (7.1). Manitoba rounds out the top five with a wage gap of 13.2 per cent.

The next highest-ranking province, New Brunswick, places 9th overall and also gets a "B" with a gender wage gap of 14.3 per cent, in line with peer country the Netherlands (14.1). Ontario (16.2), Quebec (16.4), and Nova Scotia (16.4) get “C” grades with gender wage gaps comparable to those in the U.K. (16.9), the Switzerland (16.9).

Hmm. Quebec has greater paternity leave than places with lower gender pay gaps. And, also, places with higher. We actually appear to see no effect at all, no even correlation, between better paternity leave and the gender pay gap.

Agreed, it might all be a little early and all that. Perhaps a society of displaced Frenchmen is different. Or a still largely Catholic society is. But we don't have any evidence that the policy works, do we? 

Our own reading of this and the situation in general is that it isn't maternity or paternity leave itself which causes the pay gap, it's the decades long difference in life and work priorities that does. Something we think might be rather harder to change in a sexually dimorphic species.

The document that changed the world

Forty years ago, in 1978, 18 farmers from the village of Xiaogang in China, met at night in secret. They had seen subsistence and famine. Exhausted and emaciated, they lacked the energy to work the collective fields as Party discipline required. A few years earlier they had seen 67 of their 120 population starve to death in the "Great Leap Forward" Now they took matters into their own hands. By flickering lights (none had seen electricity), they came forward in turn to sign a document dividing up the collective farm into individual family plots, whose owners could keep most of the proceeds of their labours.

They knew the dangers, and added a clause to the contract pledging that if any were betrayed and executed, the others would raise their children until aged 18. Following that historic contract, the village produced more food next harvest than it had in the previous 5 years combined. Surrounding villages spotted what happened, and the farmers of Xiaogang were exposed.

Had Mao-Zedong been in power, they would undoubtedly have been exposed and executed for betraying the principles and cornerstone of Socialism. But Mao had died, and Deng Xiaoping, the great pragmatist, was consolidating his power. He held off punishment until their illegal experiment had been studied, and pledged to adopt their innovation across China. Famously Deng had said, “It doesn't matter if a cat is black or white; as long as it catches mice, it's a goodcat.” Xiaogang's practices were good; they caught mice.

China leapt from being a net importer of food into being a net exporter, and the Chinese economic miracle was launched. Its growth rates since have ranged between 7% and 10%. India and other nations followed suit, and the neoliberal hegemony began. Living standards doubled. Life expectancy doubled. Deaths from disease and malnutrition went down to a tiny fraction of what they had been, as did deaths in childbirth and infancy. It has constituted the greatest economic advance the world has ever seen, and the greatest improvement in history in the living standards and life chances for ordinary people.

It began with a piece of parchment secretly signed by trembling hands in the flickering light of 40 years ago, but it has reverberated around the world. Those 18 brave souls who defied authority to try a new way of doing things were the pioneers of a revolution that has transformed the prospects for humankind. We salute them today.

It's definitely, absolutely, a measurement error - just, well, how large a one is it?

As Paul Krugman pointed out, productivity isn't everything but in the long run it's pretty much everything. That productivity of labour is the largest, by far, determinant of future living standards. Thus the recent slow down in the labour productivity numbers is something to worry about. Most people getting this wrong, including Martin Wolf:

One possible explanation is mismeasurement. It is, and always has been, difficult to measure the impact of new technologies, particularly now when many services are free and many are provided, invisibly, from outside the US. Yet it is hard to accept that measurement suddenly became more difficult in 2005, when the US productivity slowdown began.

He mentions that only to dismiss it as not being the true reason. Yet it is the true one, Hal Varian is right, GDP doesn't deal well with free.

The various possibilities are that we're not having a technological revolution, we're just about to have one, the rich are taking all the gains, or we're measuring it wrong.

So, the example we've oft used. WhatsApp provides telecoms services to some 1 billion people. It takes the labour of some 200 people to do so. There is no price associated with this service. No advertising, no fee, therefore where it appears in GDP is a little odd. For the only thing we do see are the wages of those who provide it. We just don't see any consumption nor production value, only those costs.

The effect of this is that WhatsApp appears in our global economic statistics as a reduction in labour productivity. We've got labour costs, no associated production nor consumption, that's a decrease in productivity.

So, we've a system whereby 1 billion people getting free telecoms off the labour of 200 people is recorded as making us poorer, lowering labour productivity? That's madness, isn't it. It's also an obvious measurement error. Thus the answer to our productivity problem is measurement error, isn't it?

The only thing left to argue about is whether measurement is some, most or all of the problem. We'd say more than all of it ourselves but we're willing to listen to counterarguments.

Reality in the NHS

Last week I went to an 80th birthday party with a difference. The birthday boy failed to show on account of having died two weeks earlier. The family decided to continue with the arrangements, balloons and all, as rather a jolly wake. The family all agreed was that he would have been there if he hadn’t agreed to yet another round of chemo. It was very disagreeable for him and it killed him.

No one is blaming the doctors and nurses. They are wonderful and have the best of intentions. He made the wrong choice or maybe the system made the wrong choice. A man with a hammer goes around looking for nails to knock in. As Atul Gawande showed in his splendid book, “Being Mortal: Illness, Medicine and What Matters in the End” (2014), specialist medical practitioners look to use their skills. It is what they do. The consequence is an excessive number of over-worked specialists and a shortage of geriatric specialists who can take a holistic view.

That is symptomatic of so many areas in the NHS where savings are not only possible but would benefit the patients. One reality is that the NHS will need more money. If the Prime Minister does provide it then she is acting irresponsibly–because she is doing so without also ensuring real reform. For a start, productivity will decrease.

Lord Warner was a Health Minister during the Blair government and witnessed exactly that. His book, “A Suitable Case for Treatment - The NHS and Reform” (2011), documents what happened when the NHS was given large sums of new money but little improved because it is an unchallenged monopoly: “This monopolistic power shows in the attitude of many NHS staff and their resistance to external providers and reform. While I was a Minister, the health team regularly had meetings with groups of NHS staff, with everyone from porters to consultants, but with no senior managers present. When asked what they would most like me as a Minister to do, they invariably asked me to stop change.”  

Listing the areas of NHS waste would take more space than this Blog allows. Some are massive: such as procurement and the external bureaucracy now committed to it. NHS constraints on surgeons and consultants lowers their productivity relative to their private work. Spending £180m a year on back injections and surgeries the medical community decry as useless. Prescribing over-the-counter medicines which the NHS forbids every few years. Refusing to recycle medical devices, such as crutches, or unopened packets of medicine.

Some are less serious: such as throwing away metal scissors and tweezers after one use. They used to be sterilized in boiling water but scientists have shown that “prions” (Mad Cow disease) are not destroyed by boiling. The grand total of UK cases of Mad Cow disease is two in the last eight years, both likely due to long ago blood transfusions from an asymptomatic patient who'd eaten infected beef–with no known instance of the disease being caused by surgical instruments.

The second reality is that the Department for Health and Social Care and NHS have more reasons to conceal waste than to come clean. Transparency would undermine their case for more money and it would increase the pressure for reform. Ministers can be fobbed off with promises of savings (procurement being a good example) without those savings actually being tracked and delivered. Worst of all, as Lord Warner discovered, transparency would mean change.

The NHS, like all those reaching three score years and ten, embarrassingly pretend everything is and will be as it once was. The reality is that the NHS should adapt. That does not mean accepting the whims of a few politicians as led to the unfortunate 2012 Act. We need creative thinking by well-informed experts. There has only ever been one Royal Commission strategically to review the NHS and that was 40 years ago. Be it a Commission or a more informal Convention, let us have a non-partisan strategic review now. Once the consequential reform has been put in place, then of course the necessary funding can flow.

We're very taken with George Monbiot's latest idea

Our general view of George Monbiot is that he spends far too much time thrashing around in ignorance to be a reliable guide to anything very much about the world. Yet there are indeed those times when the frantic search produces the odd nugget of interest. As with this demand of his:

He gets almost everything wrong. But last weekend Donald Trumpgot something right. To the horror of the other leaders of the rich world, he defended democracy against its detractors. Perhaps predictably, he has been universally condemned for it.

His crime was to insist that the North American Free Trade Agreement (Nafta) should have a sunset clause. In other words, it should not remain valid indefinitely, but expire after five years, allowing its members either to renegotiate it or to walk away.

George insists that all trade treaties should have such sunset clauses.

Note what a sunset clause is. It isn't an assumption that matters will continue as long as there's no vote against it. It's also an insistence that one decision once isn't the end of matters. It's an insistence that without a positive vote in favour of some treaty then it falls. No one does get to say that's just part of the settled system, it has to be positively approved every 5 years.

Which would make for an interesting world, wouldn't it? That Single Market of the European Union is a trade treaty. It would need a positive vote in favour of it every 5 years, would it? The Customs Union seems to be similar. And if this applies to trade treaties then why not to other ones? Membership of the UN, the Paris Climate Agreement, Montreal Protocol, why shouldn't these all be subject to that approval requirement? They all failing without it?

Well, of course, we know why not. Agreements approved of by George won't and shouldn't be so subject, those disapproved of should be. But it would be an interesting world if all such agreements were subject to that positive democracy, wouldn't it?  

Chaotic but interesting.