Who cares about Adult Social Care?

Obviously all those wonderful people who provide it, and their clients, care but as one moves up the management hierarchy, the question becomes more difficult. For a start, no one in Whitehall has much responsibility for Adult Social Care. According to the King’s Fund “Spending on adult social care services by [English] local authorities fell from £18.4 billion in 2009/10 to just under £17 billion in 2015/16, a real-terms cut of 8 per cent” although that is being topped up with some funding from the NHS. The NHS overlaps with Adult Social Care notably for the elderly and those with mental health problems, the two fastest growing problems of our time. Better management of this overlap would make the NHS more cost effective and better focused. Yet Cabinet Ministers rarely discuss Adult Social Care. The Chancellor, in his hour-long autumn 2017 budget statement, made no mention of it.

Local authorities carry the can but they are handicapped by knowing neither what funding will be available from year to year nor the value for money they are providing. The Care Quality Commission (CQC), remarkably, evaluates individual homes but not the service provided by any local authority as a whole. A local authority cannot improve its offering if it does not know its position in the league table nor what it is doing wrong nor how other authorities are doing things better. Still less can they see the total national picture.

If we could agree the outcomes expected from each LAASC (Local Authority Adult Social Care department), and measure and publish that performance from year to year, the less successful could learn from those getting better results and/or better value for money. School league tables may be controversial but at least they identify where best practice may be found. Dividing outcomes by the annual costs of each LAASC as a whole and per client would give indications of productivity. Such measures inevitably will be crude but even so the apparently most productive should provide insights for those with less attractive indications.

iMPOWER, a consultancy working exclusively within the public sector, has taken some bold steps in this direction. For 150 LAASCs they measured costs and performance in three “domains”: older people’s services, all age disability and health and social care interface. The second domain’s metrics are muddied by children’s social care and the third by some NHS costs but they have had to make the best of the metrics available. If this broad approach was adopted nationally then more precise outcomes and measures of those outcomes could be agreed and synchronised, replacing the current data reporting so that no net additional bureaucracy should be needed.

For each domain, iMPOWER selected six to ten outcome measures, from the Adult Social Care Outcomes Framework, and then set those against published expenditure to calculate productivity scores (the most current nationally available data on which was from 2016/17 budgets and outcomes). This provided an LAASC productivity ranking for each domain. Each overall LAASC rank was the mean average of its three domain rank positions.

Clearly there is plenty of room for debating the outcomes, their measurement and the methodology for integrating them into useful performance and productivity indices. iMPOWER should be congratulated on getting the show on the road and encouraging LAASCs to improve what they have done. Motivation is key and therefore iMPOWER have elected only to publish the names of the ten most highly ranked LAASCs. Every LAASC will be told, if it asks, what its ranking was and how that was calculated but not how the other 139 fared.

To be effective, this approach will have to be totally transparent. Every LAASC should want to know how comparable LAASCs scored but the experience of introduced school league tables shows that such systems need to be introduced slowly and gently.

Reducing outcomes to single productivity indices is likely to be an over-simplification too far. An LAASC may be great for elderlies but hopeless for mental health. Therein lies much of the benefit from this type of analysis: highlighting the particular areas for improvement. The usual convention is to have a “dashboard” of the key indicators. These are used by children’s services departments and an agreed national standard set for LAASCs, monitored by the CQC, would serve this sector far better, and at much less cost, than a management hierarchy such as that in the NHS and the Department of Health.

As we know it's possible to make Scottish wine

It's not just that we can make Scottish wine, we do, as the existence of Buckfast tells us. Although we've a certain suspicion that it's not actually the wine that comes from Scotland. But as Adam Smith did say:

By means of glasses, hotbeds, and hotwalls, very good grapes can be raised in Scotland, and very good wine too can be made of them at about thirty times the expense for which at least equally good can be brought from foreign countries.

Given the journalistic tastes of some of us around here we can't quite agree that wine 30 times the price is a good idea. In fact, as with the original injunction, why not do something else and buy 30 times the wine from Bourdeaux. Perhaps, say, grow that barley Scotland does so well and make whisky? Some of which we could trade for wine? 

Which brings us to this insistence

With English fizz more of an emerging category than its entrenched cousin across the channel, the co-founders had to secure the best of the best of British grapes.

Clough had enough vineyards from which to source; in England, he explains, there are about 500, producing enough fruit for, on average, 5m bottles a year, two-thirds of which is sparkling wine.

"One million new vines went into the ground last year, which should result in another 1m bottles within the next seven to 10 years," says Clough.

"The [fermentation process] means that it's a long game, but contrary to what some people think, Britain can produce a premier sparkling wine."

We've no doubt this is possible, our question is why would we bother? Entirely true that what people do with their own resources, their ships they float upon the sea of commerce, are entirely up to them. As long as they are indeed using their own resources, not our.

But still, expensive wine just doesn't seem to be the way to go, even with so many opting for a dry January.

Fat Cat Thursday

Today is Fat Cat Thursday. It marks the fact that in just three working days Britain’s top bosses will have earned more the average full-time employee will over the whole year. The High Pay Centre (who publish this stat) argue that this is evidence that CEO pay is too damn high. The Times believe that executive pay is damaging the reputation of free markets. And the Prime Minister agrees, she thinks that firms that offer CEOs massive pay packets are ‘the unacceptable face of capitalism’.

Hogwash! CEOs are paid handsomely because the decisions they make are so important. When Microsoft’s CEO Steve Ballmer waited too long to invest big in smartphones, he destroyed share value magnitudes higher than his pay. The right CEO can take a firm to the next level (e.g. Steve Jobs at Apple) and the wrong CEO can bankrupt a firm. Is it any wonder that firms are willing pay millions to get the right one?

Some argue that while CEOs are important, today’s CEOs are no more talented than CEOs ten-twenty years ago. They bring up the fact that over the last ten years executive pay has risen by 80% while returns to shareholders have only increased by 1%. But, as Sam Bowman points out that comparison is misleading. CEO pay (£525m) is just a small fraction of returns to shareholders (£75bn in Dividends). 1% of a very big number (1% of £75bn is £750m) can be worth more than 80% of a much smaller number (80% of £525m is £420m).

It is the equivalent of arguing that spending on cybersecurity has quadrupled but profits are flat. That may be the case, but it doesn’t imply spending on cybersecurity is a bad idea. As Intel found out today.

When I debated the High Pay Centre’s Stefan Stern on LBCthis afternoon he argued that, paraphrasing, today’s CEOs are no more talented than CEOs in the past, and so questioned why they should be paid more. They should be paid more for the same reason Harry Kane is paid more than Alan Shearer. CEOs, like Premier League footballers, have become relatively more valuable. Just as Premier League matches are now screened across the world. This is backed up by research from Quigley, Crossland and Campbell. They looked at unexpected CEO deaths and their impacts on share prices. This allows them to control for the fact that when CEOs are fired, even more bad news is often revealed at the same time. They found that since the 50s while good CEOs cancelled out the impact of bad CEOs, share price changes in either direction were much higher.

Why’s this the case? I can think of two big reasons.

1. Globalisation

Globalisation has increased the risks associated with bad decisions but also increased the reward associated with good decisions. If a CEO makes the wrong investment, it could lead to an international competitor snatching market share. On the flipside, the potential upside of being a market leader not just in the UK but also the US, China and Japan means that good CEOs are more valuable.

2. Intangible Capital

As Stian Westlake and Jonathan Haskel argue persuasively in their book Capitalism without Capital, business today is as much about tangible machinery as about branding. In the past, if General Electric’s CEO overinvested in microwaves and under-invested in cars, they could at least sell those machines on to other firms. Perhaps not for as much as they paid, but not for nothing either. That’s not the case with branding. Take Burberry, before Angela Ahrendts became Apple’s top paid executive, she was in charge of turning the Burberry brand around. When she joined, it was a downmarket brand tainted by its association with ‘chavs’. She made the call to close factories to reduce counterfeits and cut out cheaper products. As a result, Burberry once again became a luxury brand and the fashion house’s share price more than doubled. If Burberry hired a different CEO, the brand might have been permanently associated with bad taste. You may be able to sell off a sewing machine, it’s much harder to sell off a tainted brand.

If CEOs are as valuable as stock markets think (and remember if they are wrong there is big money to be made) then crackdowns that scare off top talent could be a disaster for British businesses.

If we're to speak of land wealth then we must get it right

Is a significant portion of the national wealth in land and or housing? Yes, it most certainly is. What's not quite true as this following claim though:

But ignoring land is a mistake. Despite the explosive growth of corporations since the Industrial Revolution, land still represents a huge percent of all the wealth in the economy. What’s more, focusing only on capital gains neglects the extremely important fact that land earns income from rent. If you live in your own house, this income is implicit -- living in your own home means you don’t have to pay rent to someone else. But if you’re a landlord, you get checks every month, just like stockholders receive quarterly dividends. And in the same way that a stockholder can use dividends to buy more shares, a landlord can use rental income to buy more property -- thus, rent needs to be counted in the return to housing.

And that total return is higher than people realize. According to new research, the return on residential real estate has been as high as or higher than the return on equity. As modern economies have grown and developed, owners of the ground on which we live have been steadily enriched.

This simply isn't correct. Land as a portion of national wealth has declined enormously over the past century and a half of capitalism. Quite the most remarkable change in fact has been the destruction of farmland - those grand aristocratic estates - as a factor in the calculation of that national wealth.

For people are getting confused here, It isn't the land upon which our houses stand which is valuable. It is the permission to put a house upon that land which is. This goes back to that point we so often make, agricultural land is perhaps £10,000 a hectare in the SE, land with planning permissions some 100 times that. The same is true of the land which sits under the houses already built.

That is, the rise in "land" as a portion of wealth entirely disguises the reality, that it's gone from being some small number of great estates to being the land under owner occupied housing making up that wealth.

We could also change this quite a lot by having a sensible planning regime of course. But it's still important to understand that it's not some class of landlords, rentiers, controlling that wealth being talked about. It's us. Which does rather change what we do about it, no?

Give Lord Price a megaphone

Lord Price, previously CEO of Waitrose, was appointed Trade Minister at UKTI, now the Department for Trade and Investment, in April 2016. Finally the government had appointed someone to lead our exports who really knew something about business. For the preceding 20 years, UKTI had seen a near-annual churn of ministers and ill-judged policies. The churn was stirred essentially by mandarins who thought they knew more about exporting than exporters did. Yet just eighteen months later Lord Price was gone too.

This week he gave an interview to the Daily Telegraph calling for government to hand export promotion to "a German-style network of chambers of commerce". He is right because exporting successfully as a start-up is not a matter of mathematics, digital analysis or micro-economics but of personal human contact. Exporters and importers need to meet and know each other. The best people to show the way are those who have already 'been there and done that' - not civil servants in Whitehall and embassies.

The idea is not new: the British Chambers of Commerce (BCC) have been pushing it for some time. In 1991, Michael Heseltine, then President of the Board of Trade, proposed something similar also based on the German network of chambers of commerce. It was called “Business Link”.  BCC not only failed to grasp the opportunity but opposed the whole idea. 

Reviewing the matter 20 years later, Heseltine stated that the BCC: “should have gone to Government and said, look you've got all these services, work with us and create the one stop shop. That's what they should have done. We did it for them. I think they regarded Business Link as an intrusion into their fiefdom. But the reason we created Business Link was because the Chambers weren't doing a good enough job."* In the event, Whitehall mandarins appointed themselves to the key Business Link positions so that was a disaster too.

Lord Price’s argument is cogent and no-one is better placed to outline the way forward. Remarkably, instead of welcoming what could be regarded as their own proposal, the BCC's response was to grumble about who should pay for it. Lord Price suggested businesses pay “a small levy – say £100 to £1,000”. Adam Marshall, the Director General responded that such a levy would be seen ‘as a “tax on business” and turn the chambers into quasi-governmental organizations that would be less free to argue fearlessly for business interests.’** Even by BCC standards, this is a miracle of contrariness: he is claiming that members paying dues to a private club, or trade union, for representation, and the provision of services, would thereby inhibit that club from so doing.  

It is unfortunate that funding is muddying the water at this stage. The government export department costs around £400 million p.a. but there is little reason why it shouldn't focus solely on things only government can do (treaties and such like) with a majority of that £400 million, i.e. £1,600 or so per exporter, released to fund BCC’s export services and those of its overseas partners. No new levies or taxes would be needed. 

While Heseltine’s issue that chambers aren’t yet doing a good enough job, we could always suggest the possibility that government should pay chambers by results. A scorecard would need to be agreed and a scorekeeper (perhaps a business school with strong international marketing expertise, to collect and publish the scorecard) but this is not an insurmountable obstacle. Some chambers are excellent and are already helping the members to export in significant ways. Inevitably some chambers are better than others and, overall, they are not up to the standards strongly exporting countries like Germany. It is no criticism to say that they could do better: every organisation in the country could do better. Suggesting complacency, or that helpful opportunities are being opposed, is not a criticism I would make. 

We can be sure that the mandarins will oppose Lord Price’s suggestion and ministers will claim to be pre-occupied by Brexit, forgetting that a key rationale for Brexit is the very freedom to export to which Lord Price is opening the door.  We know this because Lord Price must have outlined his thinking before leaving office after a mere eighteen months.

To take his proposals forward he needs to set up his own working party with the BCC, other business groups, experienced exporters and academics. The House of Commons International Trade Committee should discuss the proposal. It needs to be refined until business speaks on it with one voice. Then give Lord Price a megaphone and government will have to listen.

* Forte, Elliot (2011). Intervention: The Battle for Better Business. Lulul. pp. 252–264. ISBN 978-1447863236.

** Daily Telegraph, ibid.

Open access on HS2?

As the cost of HS2 continues to rise at an alarming rate there needs to be far more detailed analysis over its benefits. With wider time savings negligible, the project’s only real raison d'être is a much needed boost in capacity. The existing ‘West Coast Mainline’ which connects Scotland, NW England and the West Midlands to London is currently running close to capacity threatening future growth without new lines.

The current tender for the new West Coast franchise incorporates both existing and new HS2 services into one single operation giving an even bigger monopoly than is currently the case. Given the eye watering cost of constructing HS2 the government is keen to claw back as much fare box revenue as possible from the winner of the incorporated franchise bid through hefty premium payments totally undermining potential for competition. Given HS2’s limited time saving - owing to the relatively short distance – maintaining the status quo let alone improving services on the existing line could prove financially disastrous to the government’s proposed franchise model. 

When trains from East Kent to London transferred to HS1 in 2009 fast services on the existing route were axed. Passengers from Ashford to London had the choice of either accepting an increase in journey time of 44% or paying a 24% premium to travel on HS1.
If this framework was adopted on HS2 - and I strongly suspect it will – there is a real risk that competition will be further undermined. Whole swathes of the NW of England and Scotland will be left paying significantly more than Virgin’s already grossly inflated ‘walk on’ fares. Manchester to London currently costs £338 for a standard class peak return; add 24% and this becomes and eye watering £419 standard or £600 first class. 

If the classic route becomes 44% slower - roughly 3hr from Manchester to London vs the current 2hr - we will have the worst of both worlds. Many other locations along the existing route such as Warrington, Stoke on Trent and Coventry risk coming off even worse with the loss of fast direct services to London without an HS2 replacement. In Lancashire and Cumbria there is talk of no direct trains at all. With the 2nd phase of HS2 only being constructed as far north as Wigan, trains will then have to transfer to the classic route onward to Scotland. To compensate for the slower line speed the current plan is to largely omit intermediate stops.

To enhance HS2 new operators need to be granted access to the existing 125mph line through ‘Open Access’ agreements. On the East Coast route this model currently works well even though it’s limited to only a few stations. Where head to head competition exists fares have fallen and passenger satisfaction has risen. HS2 provides a golden opportunity to scrap the unpopular franchise system on the West Coast route and replace it with a system that delivers real choice for passengers. 

Uber, but for ambulances?

A few months ago, I needed to head to A&E. My condition wasn’t serious enough to warrant calling an ambulance, but as a recent graduate living in London I don’t own a car: so I ended up getting an Uber. According to a new study from University of Kansas economist David Slusky and co-author Leon Moskatel, I’m not the only one who’s been in this situation.

The paper (which is currently undergoing peer-review) examines how ambulance use rates changed when Uber began operating in US cities, and looks at data from 2013 to 2015. During that period, the authors found that ambulance use rates declined by an average of 7% after Uber (specifically UberX) began operating in a city. They argue that this can be explained, at least in part, by low-risk patients substituting ambulances for Uber. If this is the case, ridesharing services are cutting healthcare costs for low-risk patients by reducing the need for expensive ambulances. More significantly, Uber and other ridesharing platforms would be freeing up ambulances for those who need them most: reducing their waiting times and potentially saving lives. Following this logic, some U.S. hospitals have considered formally partnering with ridesharing platforms for low-risk patients.

Although the study doesn’t compare cities that got Uber to cities that didn’t, the prospect of declining ambulance use being explained by regional trends is unlikely. The map below shows that Uber’s entry into major US cities was “reasonably randomly distributed across the country, with no obvious pattern by region, city area, or population”:

A more pressing objection to the study’s conclusions is that the Uber could reduce ambulance use via an entirely different mechanism - a reduction in DUIs and assaults. My colleague Sam Dumitriu has previously explored the evidence supporting this argument:

...the rate of vehicular accidents falls quite dramatically when Uber enters a city, with traffic fatalities declining by 16.6 per cent over a year. This can be explained by both a reduction in the number of people driving under the influence, as well as the fact that the people most likely to use Uber (i.e. millennials) are terrible drivers and anything that keeps them off the road is a good thing.

Second, [evidence suggests] declines in arrests for both assaults and disorderly conduct. This may be because Uber reduces passenger wait times, lowering the risk of someone being attacked while waiting for a cab.

However, ambulances dispatched to respond to assaults and DUI incidents are unlikely to make up the vast majority of ambulance use in America. It is unlikely that reductions in assaults and DUIs explain away most of the reduction in ambulance use once Uber enters a city. Either way, ridesharing services are potentially saving lives; this study is a valuable indication that Uber might be doing so in a completely different way.

Great minds think alike

In today's City AM, I argue that it is right for train fares to rise by 3.4%. Part of my argument is that it is wrong to subsidise rail users who are, on average, better off than other commuters. But I make a further argument. In fact, cutting rail fares may not even help most commuters.

"If fares were to fall on the Brighton Main Line then I may consider commuting from Hove, but landlords would anticipate this and raise rents. Homeowners and landlords in commuter towns may welcome the windfall, but it is hardly reasonable to expect taxpayers to pay for it."

On Twitter, Tom Papworth (author of The Green Noose) points out that I am far from the only person to make this argument. Winston Churchill in 1909 wrote:

"Some years ago in London there was a toll bar on a bridge across the Thames, and all the working people who lived on the south side of the river had to pay a daily toll of one penny for going and returning from their work. The spectacle of these poor people thus mulcted of so large a proportion of their earnings offended the public con-science, and agitation was set on foot, municipal authorities were roused, and at the cost of the taxpayers, the bridge was freed and the toll removed. All those people who used the bridge were saved sixpence a week, but within a very short time rents on the south side of the river were found to have risen about sixpence a week, or the amount of the toll which had been remitted!"

Great minds eh...

We must do as Polly Toynbee says, we should be more like Sweden

A depressing truth about our world - people don't value things which are free:

Missed hospital appointments cost the NHS almost £1 billion a year and deprive patients of vital care, the health service’s top nurse has said.

As the service heads into what is likely to be the busiest week of the winter, Jane Cummings, the chief nursing officer for England, called for the public to be more responsible about wasting time and resources.

A million more cataract operations or 250,000 hip replacements could be funded if the NHS did not have to pay for appointments that people failed to attend, she said.

Official figures show that 7.9 million appointments were missed in 2016-17, meaning that patients do not turn up to one in 15 of the 119 million scheduled. At an average cost of £120 per slot, this indicates that doctors’ time worth about £950 million was wasted last year.

This is, of course, a pure economic waste. We are being made poorer by this amount simply because people are not turning up to those "free" appointments. This is, equally of course, something that we'd like to change.

We could, yet again of course, just insist that all should buck up and do their duty. Or we could follow Polly Toynbee's constant and consistent mantra, that we should be more like Sweden. That is, have a little judicious application of economic incentives.

The overall costs of an appointment there are about as they are here, perhaps 1,800 to 2,000 SEK, or in that £160 to £180 range. Given government accounting that is pretty similar to our own costs. But the Swedish insist that the patient - or would be patient perhaps - must personally cough up in the £10 to £20 range for the service. 

No, this isn't some charge to pay for the system at all, it's purely an incentive for someone to turn up when they say they wish to turn up, it's a management of the capacity of the system charge, not a revenue raiser. In much the same manner as we pay a prescription charge in fact. Larded around with all of the exceptions as well, people who need many prescriptions/visits pay a reduced or capped amount.

The thing being that people value more what they've got to pay for. Even at a 90 to 95% discount, people still value such things more if they've got to cough up for them.

Or as we could also put it, as those socially democratic Swedes do it, at least one solution to the problems of the NHS is to stop it being free at the point of use.   

The NHS is an historical relic, not a Wonder of the World

Given the anniversary we're going to get an awful lot more of this sort of rhetoric:

The NHS will celebrate its 70th birthday in 2018, after a difficult decade since the global financial crisis culminating in one of the most testing years in our history. The terrorist attacks in London and Manchester, along with the Grenfell Tower tragedy, saw all emergency services, including NHS staff, respond with skill and bravery.

Our health service, while still ranked among the best in the world, has never been busier. The NHS sees almost 1.5 million patients every day in England alone. So as well as celebrating its many achievements, in our landmark year we must also reaffirm our commitment to a taxpayer-funded service, based on clinical need and not the ability to pay.

In 1948, at the NHS’s founding, there were no routine antibiotics, anti-cancer drugs or blood pressure treatments, and infectious diseases were common. This has all changed, thanks in part to British science, which has brought the world vaccination, penicillin, IVF, stem cell transplants, artificial hips and MRI scanners, and knowledge of the structure of DNA.

But our greatest innovation by far, with the most far-reaching impact on the health of our nation, has been the NHS. It embodies the British social conscience. Since resources are very stretched, some may question the funding model, and suggest the NHS is not fit for the future. Nothing could be further from the truth. Scientific advances mean it is needed more now than ever before.

Certainly British science has informed what the NHS does. British science has also informed what all other health care systems do, so Bully for British Science! Yet the science of everywhere else has also informed what the NHS does - science is, after all, a public good.

However, what is really being celebrated here is the unique manner in which the NHS is organised, something thought so basic that it has replaced the CoE as the national religion.

The truth being - a useful, not complete, truth - that health care systems around the world are fossilised into whatever the favoured structure was in each country at the time that a health care service became a useful thing to have.

It is harsh but roughly true that pre-WWII the major function of hospitals and all was to provide bed rest. After WWII we began to have that scientific revolution which meant that active treatment of ever more conditions was likely to be successful. Exactly and precisely those vaccines which killed off many of the infectious diseases, the antibiotics, near any treatment for cancer other than hacking away and so on.

That we've got this wondrous science being applied to our health is just fabulous. But as we should be able to note this happens in all of the rich countries, it's something that is independent of the precise manner in which it is organised. Germany, France, Switzerland perhaps, rely upon state supported insurance, the US (and badly) on a more bureaucratic and also market approach (the combination of the two never likely to work well), our own NHS on a near Stalinist state provision model. These are just the ideas which were around in the varied places in the 40s and 50s when that science meant that a comprehensive health care system was viable and desirable.    

That Singapore, coming very much later to the game, has a very different structure (essentially, state run and paid for catastrophic care, forced savings accounts for routine) is really a reflection not of the underlying society but that we all knew more about the incentives that drive health care structures when it was designed. 

Leave entirely aside, for a moment, what we think the structure of a health care system should be. As all around us leap with joy over this anniversary we need to recall that the current NHS structure is only, really only, a reflection of how 1940s Britain thought things should be arranged. 1940s other places had a different ruling ethos which is why they have different health care structures. And there's absolutely nothing at all in the evidence since then to tell us that 1940s Britain had it right.

Far from being the Wonder of the World the NHS is an historical accident. Other places do it differently- it might be worth our considering whether that decision taken 70 years ago came to the right conclusion.