Who carries the can for adult social care?

According to its website, “the Department of Health (DH) helps people to live better for longer. We lead, shape and fund health and [adult social] care in England, making sure people have the support, care and treatment they need, with the compassion, respect and dignity they deserve.” One of the three Parliamentary Under-Secretaries leads on “care for the most vulnerable, mental health, adult social care, community care, injustices and vulnerable groups, women and children’s health, health and work [and] blood and transplants”.

That may seem a little confusing given that the DH's overall responsibilities can be divided more simply into three: medical treatment, adult social care and public health.  “Community care”, i.e. care in the community, is a subset of “adult social care” which also covers care homes – some of which are small enough to see themselves as being in the community. “Under the 1990 National Health Service and Community Care Act any adult aged 18 or over who is eligible for and requires services from the Local Authority has the right to a full assessment of their needs and the services provided should be individually tailored to meet those assessed needs." Adult vs. community care is not a useful distinction.

None of the 27 DH quangos is devoted wholly to adult social care although some, such as the Care Quality Commission which critiques both care and medical treatment institutions, have some involvement with it.  Of the 32 DH advisory bodies, only one, the Health and Social Care Advisory Panel, has some limited involvement in adult social care (“open data strategy”).

In summary so far, Whitehall’s responsibility for adult social care lies with the DH but it appears to have little capacity for exercising that responsibility.  The current fashion is to call for the integration of the NHS and adult social care.  Better linkage can indeed improve their cooperation at local level, like has happened in Manchester, but the NHS is already too big to manage and total merger makes about as much sense as merging the Titanic with an iceberg.

Much of the NHS' troubles flow from internal squabbles over how the money is spent.  At least it all comes from the DH.  In the case of adult social care however, Whitehall’s share of the funding comes from the Department for Communities and Local Government.  How crazy is that?  Suppose, for example, the DH decided to remove hospital bed blocking by transferring the savings to adult social care.  It would not happen because no self-respecting Whitehall department hands its money over to another department. The DH has responsibility for adult social care but not the finance or authority to meet that responsibility.  

Local authority expenditure in 2016/17 is budgeted at £94.1bn of which adult social care costs £14.4bn. and education costs £34.2bn.  The DCLG contribution is budgeted at 53% or £50.1bn. In other words if the total funding of adult social care and education was transferred to the DH and DoE respectively, with local authorities simply acting as agents, policy and resources would be aligned at no cost to the taxpayer.  The DCLG’s financial responsibility would be reduced to £2.4bn, and ultimately nil, which they would hate but who cares about them?

Adult social care is widely seen as an important and growing problem.  The Care Quality Commission reported “While so far the sector has been more resilient than some anticipated, we are concerned about the fragility of adult social care and the sustainability of quality.” The under-funding of adult social care is contributing to the difficulties of the NHS. At the national level, who carries the can for it?  In reality - almost nobody.  Yet this circle, as shown above, is not hard to square. If the Prime Minister could spare five minutes from Brexit, she could do so.

Don’t be scared by the elephant chart: it shows that most of us are getting richer

Despite many qualities, the Archbishop of Canterbury speaks as though he is shamefully illinformed and lazy-minded about the global economy, making hasty, ill thought out assertions about how society is so horribly unjust, and that the poor are getting the roughest deal of an economy that needs to be distributed less unevenly.

Here is the actual reality of what's been happening, illustrated in Branco Milanovic's elephant shape graph of the years 1988 to 2008. The horizontal axis shows global income percentile in terms of the world's poorest and richest people, and the vertical axis shows the real-terms percentage change in incomes.

image1.jpg

The summary of why it's an elephant shape can be explained in roughly this way.

  1. The world's very poorest (the very small proportion of people to the far left on the horizontal axis) have not gained significantly. They are the minority that have not yet been able to benefit from globalisation, mostly due to being excluded from entering the global market (for reasons like dictatorships, civil war and lacking basic human rights, but for another significant reason I'll mention in a moment).
  2. The entirety of the elephant's body, ending at the top of its head, shows the gains in prosperity of all the rest of the world's poorest people in emerging countries - it's the biggest explosion of progression for the most number of people the world has ever seen.
  3. The dip just after that, at the formation of the elephant's trunk, is the people in the world's most well off two dozen countries whose incomes haven't risen to the same extent - but that's primarily because: a) they are already in the top 75-90% of the world's wealthiest people who have ever lived, and have consumption and prosperity levels that even their grandparents would marvel at; and b) because much poorer people have been gaining by entering the market and being more competitive (which, if you're paying attention, is actually of benefit not just to the people in number 2, but also the people in number 3 as they benefit in terms of more affordable consumption of those goods and services).
  4. The people that make up the rest of the elephant's trunk comprise the world's richest people. And as expected, they have made significant gains too, because the world's top entrepreneurs are the main people creating the jobs and opportunities for all the people in groups 2 and 3 - so of course they are going to see gains. They become better off by making large proportions of the global population better off too. And don't mistakenly think that the world's richest people are only the yacht-owning multi-millionaires - you only need to earn just over £24,000 per year to be in the world's top 1% of earners.

Milanovic's graph isn't perfect: some of the stats that comprise the low point at the elephant's trunk are also countries in significant transition periods that hit a low; and faster population growth in the economies of groups 1 and 2 means that the people at the low point at the elephant's trunk are not always precisely the same people in both 1988 and 2008.

But the general trend holds: although some workers in the 75th percentile have seen their wages fail to rise because of low-wage competition in growing economies, the vast majority of the world's population are being made better off by globalised trade, not just in terms of rising incomes, but lest we forget, in terms of consumption too (better technology, more goods and services, more affordable products, enhanced communication, fewer working hours, etc).

Finally, I said earlier that there is a minority of people in the world that have not yet been able to benefit from globalisation by being excluded from the global market due to malevolent influences in their own countries. But we cannot ignore the part that politicians in the most prosperous countries play in the continuation of their plight. The sad reality is, there are still too many barriers to free trade, as many of the people in group 1 are kept in group 1 by regulations constructed by governments of people in groups 3 and 4 to favour groups 3 and 4 over groups 1 and 2.

For all those reasons, and more, I think now would be a nice point in human history to let reality and a sense of perspective rule over half-witted, half-thought-out attacks on the free market.

Policy in Practice and interesting assumptions about welfare reform

Policy in Practice has done a "report" for the LGA about the effects of welfare changes. The result being that millions will be left wandering the streets apparently:

Over two million poor families will be more than £50 a week worse off by the end of the decade, according to an alarming analysis of welfare cuts, crippling rent rises and looming inflation.

In a bleak assessment of the plight of the poorest families in Britain, the study commissioned by the Local Government Association found that more than 84% of those set to lose £50 a week or more are households with children, either lone parents or couples. Almost two-thirds of them are working households, despite claims from ministers that they wish to create a welfare system that encourages work.

The major factor here is rising private rents while LHA numbers don't rise:

More than 2 million low-paid private renters face an average real-terms loss of £38.49 a week by 2020.

This clearly depends upon some estimation of what future rent rises are going to be. The assumption made in the report is that they will be large. On page 16, from a little under 5% a year to over 6% a year. Cumulative, of course.

ONS has private rental costs rising by less than 2% over the past 12 months.

Yes, probably best that we file this report in that round filing cabinet under the desk then. Certainly, forecasting is necessary for these sorts of things but starting from the current baseline is useful practice.

Nicolas Maduro and the dumbest economic idea in the world

A headline in The Times:

President Maduro of Venezuela caps prices to curb black market

As PJ O'Rourke remarked in Eat the Rich:

 It's no use trying to fix prices.  To do so, you must have a product that can't be replaced, and you must have complete agreement among all the people who control that product.  They're greedy or they wouldn't have gotten into the agreement, and they're greedy so they sneak out of it.  This is what was wrong with Paul Samuelson's idea about crop restrictions in Chapter 1, and this is why the members of OPEC are still wandering around in their bathrobes, pestering camels.

     Any good drug dealer can tell you that to ensure a monopoly, you need force.  To ensure a large monopoly, you need the kind of force only a government usually has.  And it still doesn't work. ...

     The government of Cuba, with force aplenty at its disposal, decided that beef cost too much. The price of beef was fixed at a very low level, and all the beef disappeared from the government ration stores.  The people of Cuba had to hassle tourists to get dollars to buy beef on the black market, where the price of beef turned out to be what beef costs.

     When the price of something is fixed below market level, that something disappears from the legal market.  And when the price of something is fixed above market level, the opposite occurs.  Say the customers at suburban Wheat Depot won't pay enough for wheat.  The U.S. government may decide to buy that wheat at higher prices.  Suddenly there's wheat everywhere.  It turns out that people have bushels of it in the attic.  The government is up to its dull, gaping mouth in wheat.  The wheat has to be given away.  The recipients of free wheat in the Inner City Wheatfare Program hawk the wheat at traffic lights, and what they get for it is exactly what people are willing to give.

There is indeed a tragedy in the fact that the President of Venezuela knows less economics than the humour correspondent for Rolling Stone.

The underlying point being that supply, demand and prices are not an optional part of our universe, they are how we humans interact with it. The only choice we have is whether we make such interactions safe, legal and commonplace or dangerous, backstreet and rare.

As ever with Polly it pays to study the details

The latest bright idea from Polly Toynbee is that we shouldn't sue the NHS when they irretrievably screw up a life through negligence because....well, that bit is rather left unsaid. We're in that penumbra of It's The Wonder Of The World and we should dance in the Olympic Stadium in praise rather than critique in any manner.

As the NAO points out, the costs of such negligence have risen substantially in recent years. Those costs are not quite as Polly, who presumably has read the report, manages to mangle

But one reason for official defensiveness is the soaring cost of insurance against claims, and insurance companies telling them to admit nothing. If fear of massive payouts from threadbare budgets were lifted, complaints could be handled faster and better.

As far as we're aware at least there are no insurance companies here. Matters are dealt with by NHS Resolution, itself funded by a levy on the Trusts. This is a useful and sensible manner for an organisation of this size to insure by the way. The risk pool is large enough that there's little point in trying to spread it further.

This is also wrong:

There used to be a concept of crown immunity that spelled out the special social contract between citizen and service. Is it time to return to something like it? Citizens need to ask themselves if they want ever larger sums of money drained from services to go to a few claimants who can prove their case, while a great many lawyers make more than the value of the original claims: the public realm belongs to us all, equally.

Crown Immunity for civil claims was lifted on Jan 1 1948, some 6 months or so before the formation of the NHS. As Frank Dobson pointed out in the Commons:

Crown immunity was first substantially undermined —if that is the right word—by the Crown Proceedings Act introduced by the Labour Government in 1947. It was felt necessary to move with the times and at least give individuals the opportunity and right to sue the Crown for damages. However, the Crown Proceedings Act does not permit criminal proceedings against the Crown or any of the agencies presently covered by Crown immunity. As a result, many laws do not apply to Crown property or to Crown institutions.

We find ourselves in the strange position that a health authority can be sued by an injured individual in the civil courts, possibly over being poisoned as a result of something going wrong in a kitchen, but the health authority cannot be prosecuted under the criminal aspects of the food hygiene regulations that the authority was breaking.

What Polly is thinking about is the lifting of Crown Immunity in respect of the regulatory apparatus, not civil damages for negligence, that happening in 1990.

We think it's a little fun to point out that the right to sue for civil injury was granted by a Labour government, the part putting the NHS under the more normal regulatory system of the land a Tory one. Polly complaining about that Labour action of course. 

This still leaves us, of course, with the desire to reduce the number of claims of negligence - we're not in favour of lives being irretrievably screwed up after all.

At which point we really should be, as is already in fact being tried, importing an aspect of the US medical system. Yes, we know, we'll all be bankrupted in our beds by being charged for our health care. Or, rather, perhaps not killed in them:

Today, aviation is arguably the safest form of transportation. Last year the accident rate had dropped to a low of only four fatal crashes from a total of 37.6 million flights.

Independent investigation is at the heart of this process. Professionals are given every reason to cooperate, because they know that investigations are not about finding scapegoats, but learning lessons.

Indeed, professionals are given a legal safe space so they speak up honestly, and can be penalised only where negligence or malevolence is proven.

Independent investigation and safe space protection are equally vital in healthcare.

Staff must be assured that when mistakes are caused by defective processes, they can speak up without being scapegoated.

Only by combating the "blame culture" in the NHS can transparency and meaningful change take place.

Hospitals that have developed a culture of open reporting have produced outstanding results.

The number of malpractice claims against the University of Illinois Medical Center, for example, fell by half in two years.

Virginia Mason, a hospital in Seattle, has seen a fall in insurance liability premiums of a staggering 74%.

As Gary Kaplan, its chief executive, put it: "We have a system that learns the lessons so that we can turn weaknesses into strengths".

There is indeed a solution to the problem Polly describes. It's just, as ever, not the solution that Polly proposes. Open investigation of systems and events then coming down like a tonne of bricks upon those negligent - yea even unto the actual punishment of individuals - is the way to do it. Rather than just not suing the NHS because it's a Wonder.

Socialism's the cure for famine apparently

What we might call one of those interesting claims from US academia:

In the 19th century, all of Ireland was part of the United Kingdom. Wealthy Protestant families with ties to England owned most of the land, renting small tracts to Catholic subsistence farmers. While landlords dedicated acres upon acres to raising cattle and grains for export to Britain, renters were left with scarcely enough land to sustain their families.

The plots were so tiny that tenant farmers came to rely on a single, durable, calorie-rich crop — the potato. In the early 1840s, a fungus afflicting potatoes arrived from the continent, and it devastated small farms, leading to widespread famine. One million Irish people died. Another million immigrated to Britain, Australia and North America. The population of Ireland has never recovered. Even now, fewer people live on the island now than did before the blight.

“Basically, what you had is a society controlled by what we would today call neoliberal capitalism, in which the rich viewed poor people as totally superfluous,” said Kerby Miller, professor emeritus of history at the University of Missouri. 

Those of us a little closer to events tend to think of Ireland pre-famine as being rather more akin to a feudal society than a neoliberal one. We're also pretty sure that Peel's rolling out of neoliberalism, the abolition of the Corn Laws and thus lower import prices for wheat, were a pretty good idea. Not sufficient as subsequent events showed but still a good idea.

However, it's this which produces the gasp:

“I certainly do think that the effects of climate change under neoliberal capitalism, under the governing ideology, is just going to be an unbelievable disaster,” Miller said. “Barring a socialist revolution — which completely changes the nation’s value system so that sharing, rather than competition and exploitation, become the primary values — I’m afraid I really don’t hold out a whole lot of hope.”

We would take the great lesson of the 20th century to be that the one thing socialism doesn't produce is bounteous food for the people.

But, you know, maybe things are different in American academe? 

Yeah, actually we will take fries with that...

Today the BBC led with a story from busybodies at the Royal Society for Public Health (and Slimming World – go figure…) attacking retailers that like to sell their wares to a completely suspecting public.

The public were so aware, the RSPH told us, that nearly 8 out of 10 of us have noticed that we’re being upsold to every single week.

This, the RSPH bemoaned, is a disgrace. But is it really? What’s so bad about a food retailer offering you the chance to buy a lot more food for a little bit more money? Are the Royal Society for Public Health really saying you should be banned for getting value for money?

Think about the last time you were upsold to: a snack and drink with your sandwich at Tesco, those fries and a drink with your Big Mac, the rest of the wine bottle if you buy three glasses at the pub. You'll have known exactly what you’re buying, you'll have known exactly what you were paying and you'd have had the chance to say no at any point of the transaction.

Which makes the wording of the report a little bit bizarre to say the least:

“One in three buy a larger coffee than intended, upgrade to a large meal in a fast food restaurant and buy chocolate at the till in a petrol station in the course of a typical week.”

But by buying the larger size, at a fraction more, you are indicating precisely the amount you intended to buy at an amount you are willing to spend. Upselling is at the heart of a whole swathe of retail industries. It is indeed a tool to get you to purchase more but more than that it exposes you to possibilities you might not have not known were available and more accurately reflects your preferences – as Neil Patel noted the most successful upsells are those that get a consumer to realise their true need and makes them willing to purchase further.

“People who take an upsell will generally spend around 17% more money but receive 55% more calories.”

You get a bit more product that you actually want and the company gets a bit more money. Oh look, just like trade generally, it’s a win-win.

One other finding was illuminating – that this practice is actually most likely to benefit the group that has the fastest metabolisms and the slimmest wallets - the young. In fact, Slimming World and he RSPH found that:

“Young people aged 18-24 are the most likely to experience upselling, consuming an additional 750 calories per week as a result and potentially gaining 11lbs in a year.”

We all have the chance to buy some more at a price you can choose to take, completely understanding the transaction. Has capitalism ever been so delicious?

An absurd part of the IPPR's demand for economic justice

The IPPR's report on economic justice is a target rich environment. We must, apparently, have more of our economy in manufacturing, failing to note that manufacturing as a share of the global economy is falling. More of the economy must be paid in wages and salaries, failing to note that the decline of the labour share is nothing to do with profits at all, it is because VAT rates have risen, as has self-employment. We could go on and we probably shall at some point. But this is simply ridiculous:

 By 2030, the British economy will have closed the gender pay gap and the ethnic pay gap.

The gender pay gap we have is not because men and women are paid differently. It's because, by and large, men and women do different things when they become parents. Thus the average pay of men and women varies because of the discrimination done by people about how to live their lives.

Fathers earn more than non-fathers - yes, after we've corrected for age, education and all that. Mothers earn less than non-mothers among women, again correcting for everything else that might vary. At least one study has found that there is no gender pay gap at all, it is purely and only the familial position which matters, primary child carer or not. That explains everything which needs to be explained, alone and unadorned.

Thus the demand is that in only 13 years' time we will have half of fathers being the primary child carer? We do think that's possibly a bit more of a social revolution than is likely to happen.

The aim is laughable because they've not understood the reason for what they are observing, never a good basis for policy making.

To really rip off the people you need to be a government

The Guardian is making much of this Azerbaijani Laundromat, the idea that people linked to - allegations as yet of course - the government of Azerbaijan have been using banks and limited companies to siphon money off to do all sorts of things.

Azerbaijan’s ruling elite operated a secret $2.9bn (£2.2bn) scheme to pay prominent Europeans, buy luxury goods and launder money through a network of opaque British companies, an investigation by the Guardian reveals.

Leaked data shows that the Azerbaijani leadership, accused of serial human rights abuses, systemic corruption and rigging elections, made more than 16,000 covert payments from 2012 to 2014.

We have no idea of the veracity of any of this, of course. But assume whichever way you prefer, it does show one thing. That to truly rip off the people you need to be the government. Only in that manner is it possible to actually force people into coughing up for such payments. Everyone else, however greedy a monopolist even, has to produce something of value in return in order to cash in.

This is thus a warning about government access to our wallets more than anything else - not a point we expect The Guardian to be making any time soon.

After Brexit, let's take the lead in free trade with the developing world

I have a piece at the Times's Red Box that argues that, after Brexit, the UK should grant full tariff- and quota-free access to its markets to many of the world's poorest countries:

The EU’s Everything But Arms (EBA) protocol came into effect in 2001 and applies to the world’s least developed countries as defined by the United Nations. Along with Haiti and a few Asian countries like Bangladesh and Cambodia, most of these countries are in sub-Saharan Africa, like Ethiopia and Mozambique. All imports except armaments from these countries face zero tariffs (taxes on imports) and quotas (rules limiting the number of items that can be brought in in a particular year). In 2014 goods from these countries accounted for €17bn worth of imports to the EU.

Countries that are still very poor but slightly more developed, like Vietnam, Kenya and Nigeria, face the Generalised System of Preferences (GSP) regime, which give preferential access to European markets compared to that of a normal “most favoured nation”. For better market access, countries must implement 27 international conventions on things like human rights, environmental protection and good governance.

The GSP is better than nothing but still holds back trade and growth. Unprocessed coffee bean imports from Kenya are not taxed, but roasted beans are at a 2.6 per cent rate. So are cut flowers and vegetables like broccoli and beans, which can face tariffs of up to 10.1 per cent. Rules like this inhibit the development of supply chains and stop value from accruing in the producing countries. And they make British consumers worse off through higher prices.

The British government has already said that it wants to continue giving preferential access to developing countries after it leaves the customs union. This is good, but we can do better. If we accept the principle that free trade makes both parties better off, it should aim to extend the zero-tariff and -quota Everything But Arms protocol to many more countries, along with less strict enforcement of rules of origin customs checks.

Read the whole thing.