Making Sense of the NHS

Much of the last election, and many elections before, centred on the claimed inadequacy of the NHS. The same arguments have circled for decades creating heat rather than light and, importantly, social disaffection without progress. Adversarial political mudslinging and ill-advised interference have damaged NHS cost effectiveness and capacity, and will continue to do so until politicians leave it to the professionals.  The cross-party convention proposed by Norman Lamb, or the Royal Commission proposed by Lord Saatchi, could help bring that about.

Making sense of the NHS boils, ultimately, down to two issues.  The relatively easy one is how much HM Treasury should provide, be that from a hypothecated tax or the general pot.  That political decision should be based on the state of the UK economy, the plentiful international comparatives, the coherence of the NHS corporate plan and competing demands.  The allocation of those resources, and the rest of NHS management, should be taken out of politics. 

The convention/Commission should review the governance and scope of NHS England and the extent to which pricing should be used to cool demand:

  • NHS England is too big and overloaded with policy makers rather than policy doers – doctors, nurses and technicians. If NHS Scotland and Wales are roughly right-sized, as their separation implies, then NHS England should become six autonomous NHS Regions, i.e. public corporations like the Bank of England or BBC. The public corporation may be only the least bad governance structure but imagine how much worse the BBC would be as part of a Whitehall department.  Since adult social care is already devolved to local authorities, regionalising the NHS would allow the DH and NHS England to be downsized to just a few staff dealing with the overall allocation of resources. 
  • The NHS should be streamlined to be more manageable. The boundary of its responsibility should be narrowed to curing what can be cured and providing medical treatment.  It should not attempt to care for the incurable. Caring and curing need to be closely linked, and cooperate better, but integration would be unmanageable.  The NHS should provide individual treatment and not tackle public health as a whole.
  • Pricing, prescriptions for example, is already used by the NHS to restrain demand. Co-pricing, i.e. patients picking up some of the cost where they can afford to do so, is used elsewhere in Europe and New Zealand, and would be no more counter to the NHS original constitution than charging for dentistry.  What does not strictly need to be cured, or medically treated, could be subject to co-charging, if resources are available, for optional matters such as IVF. One way or another, demand needs to be cooled.

    The number of GPs and geriatricians needs to be increased. An aging population grows the need for geriatricians but supply has been reducing.  GPs do their best but few of them are trained in geriatrics and their interaction with geriatricians has reduced.  It is not the most attractive branch of medicine and the pay and prospects are poor. People aged 65+ now absorb about half of the total cost of the NHS. The number of general physicians is, per 1,000 potential patients, eight times greater than the number of geriatricians: the very people who need doctors most are the least well served. The British Geriatrics Society is outgunned by competing medical professional bodies.

    Mental disorders have also dramatically increased. Drawing the boundary of NHS responsibility between treatment and cure (NHS) and care (other services) for treating geriatric issues is difficult and the boundary for mental health is more difficult still.  Today, surveys indicate that about 12% of the UK population have mental health disorders and more than double that proportion of doctors – mostly due to stress. Clearly some sort of tiered approach is required to focus professional help on those with the greatest need. 

    The potential benefits from these proposals fall into four groups:
  • Improved morale, recruitment and retention of nurses, doctors and technical staff.  The continuous political fault finding, interference and reorganisation of the NHS damages staff motivation and patient satisfaction. The professionals need empowerment and clearer lines of authority. Local and national lobby groups press their vested interests to the detriment of the whole. The contribution of politics to the NHS is, in sum, counter-productive. Unfortunately, even if politicians back off, the NHS will continue to be subject to sniping by the media. Smaller organisational units would bring staff and patients closer to top management.
  • Better management of the demand for NHS services which will always, and increasingly, outstrip supply capability, not least because they are free. Ways have to be found to cut unnecessary calls on A&E and GPs. Falls by the elderly are now treated by ambulance paramedics in the patients’ homes rather than carting them into A&E.  Better for everyone. 
  • Balancing the books by continuing to streamline working methods and bureaucracy to release more patient time for doctors and nurses, simplify the allocation of resources and better interface with, and learn from, the private sector. The NHS could make much better use of IT.  GPs in England use at least four IT systems, for example, which do not communicate adequately with each other or with hospitals. Acute hospitals should move more patients (sooner) into the less expensive cottage hospitals and convalescence homes.
  •  Focusing the NHS on curing the sick, surgery, mending limbs, medical treatment and maternity. At present, only 80.5% of the NHS England funding is devoted to its core role: primary and secondary healthcare.  That streamlining would not reduce the quantity or quality of patient care and enable the adult social care budget to be doubled at no cost to the Exchequer. 

The full paper, to which this is the introduction, will be released in September this year.

A 1988 paper on the NHS published by the Adam Smith Institute, Too Big to Manage can be found here

Learning from elimination

This piece was originally delivered as a lecture by Dr. Madsen Pirie to students at the beginning of Freedom Week 2017.

Scientific discovery

David Hume had a problem with induction.  Put starkly it is that it rests upon the shaky ground of an assumption that what happened yesterday will happen again tomorrow.  Hume could not find a causal thread that linked previous events to future ones, and thought it ultimately depended on an act of faith, unsupported by evidence or reason, that linked future events to historic ones.

In the Twentieth Century Sir Karl Popper solved Hume’s problem of induction.  Popper proposed that instead of using induction to develop theories, we use creative imagination to suggest them, and then test them to see which ones work in practice.  Her called the process “conjecture and refutation,” claiming that instead of ‘inducing’ theories from past events, instead we conjecture what might be the case, and then test the conjectures to see if they can be refuted from practical observation.

Thus Hooke’s Law, for example, suggests that the extension of a spring is proportional to the force applied to it.  That is the conjecture.  We then apply weights to springs and measure the extension to see if it does indeed vary in proportion to the attached weight.  If it does not, we discard the theory.  The theories we retain are the ones that are supported by experiment; the ones we discard are those that do not.

Science proceeds by what I call a "selective death rate."  When I used this term on a Radio 4 programme series about "Learning from Life and Death," the producer found the term "macabre," as he put it.  Perhaps it is, but it simply means that we reject the theories that don't cut it.  They die.  The ones that pass experiments live on.

The upshot is that what we call our scientific knowledge is the collection of theories that have been tested, and have not so far been discarded.  Note that they are tested in practice.  It is their performance in observed tests that decides which ones live and which ones die.

Note also that the successful theories only live on until a better one comes along, one that can enable us to predict what we shall observe better than previous ones were able to do.  Like ourselves, theories are mortal, and they live only for a time.

The market economy

There is a striking parallel between this account of scientific methodology and the operations of a free market economy.  In a market economy people are free to introduce new products and processes.  They are tested in the market to see if they appeal to consumers more than do existing products and processes.  The ones that do so survive, while the ones that do not are counted out.

A market economy, like scientific method, operates through a selective death rate.  Unsuccessful products and processes are eliminated, while the more successful ones survive.  We look at the list of leading companies, and we find that most were not there twenty-five years ago.  The names that seemed so dominant then are now distant memories, their places taken by names such as Apple, Google, Amazon and Facebook.  Many of the products that were ubiquitous and dominant a quarter of a century ago are now regarded as anachronisms, to be regarded with amused wonderment when dug out of forgotten cupboards to be surveyed by today's children,

There are other important parallels between scientific method and market economies.  Scientific discovery works faster in a society where people are free to investigate, to explore and to innovate.  It depends upon freedom of information to spread new ideas and to report on the experiments that have tested them.

A market economy similarly makes faster progress if people are free to innovate and to introduce new products and processes without state or other interference or impediments. It, too, requires freedom of information so that knowledge of success can spread.

They have something else in common, too.  Both are areas in which progress can be made. In both of them there is a goal or goals, so that attempts to reach towards these can be tested against each other to see which ones approach closer to it.

In science the aim is to extend our ability to predict what we shall observe, and theories are tested in experiments to see which ones do it better than their rivals.  I part company with Popper at this point, because he thought that by proving things false we could approach closer to objective knowledge about the universe.  I do not think we can do that, because we can no more prove something to be false than we can prove something to be true.  We discard theories not because we know them to be false, but because they serve our purposes less well than the ones we retain.  The aim is to predict what we shall observe, and we retain the theories that enable us to do that better than the ones we discard.

In a market economy, our aims include being able to better our lot, to make best use of scarce resources, to be able to satisfy more of our desires, and so on.  We can test products and processes against each other to see which ones best enable us to achieve these things. 

Thus progress is possible in both science and market economies.  In science we can become able to predict more, and in a market economy we can become wealthier and satisfy more of our desires.


There is, of course, another area characterized by a selective death rate, and that is evolution.  New mutations are tested by their ability to survive and reproduce in their environment.  Those that do so live to breed and become the dominant new strain.  The ones that do not are counted out.

I would draw your attention to two significant facts.  One is that scientific discovery and a market economy both have the inspired minds of creative human beings behind them.  People think up the new theories and the new products that have to be tested. 

In evolution the mutations are random.  This means that the changes in evolution are slower than those in science or economic activity.  Innovation in biological evolution is blind, whereas in the other two it is inspired and directed.

The other significant fact is that we cannot speak of progress in evolution because there is no goal to work towards.  There is only an environment that changes in ways that allow some mutations to prosper at different times if they are better equipped to meet the new conditions.


In summing up, I myself take the view that we humans try to improve our lot, or our performance, or our understanding, and that we do so by a method of inspired trial and error.  We do it by introducing innovations and testing them in the real world.  We retain the ones that achieve our aims better, and we discard the ones that do not.  This is how we progress toward our goals.

I add in conclusion something about myself.  I am optimistic about human creativity and ingenuity.  By this method of inspired trial and error I think we can meet any challenge and solve any problem. 

We do think this is unlikely to work

Some ideas from the civil service about what to do over the train services:

Civil servants at the Department for Transport have put forward proposals to take much greater control of the running of the train operating companies, raising the spectre of the recreation of the defunct strategic rail authority.

A high level briefing document seen by The Times states: “The franchise model . . . faces real challenge — chiefly ensuring it remains commercial and politically sustainable.”

This would, as the paper goes on to point out, mean building out capabilities in that department. Or, as C. Northcote Parkinson would have pointed out, the aim and intent of every bureaucracy is to expand the budget of that bureaucracy.

However, over and above the usual self serving nature of the proposals we're really quite sure that this isn't going to work:

It continues:

“Reforms may be required to better manage uncertainty, eg HMG [the government] retaining more or all revenue risk.

Which of the various lines is it that has the general public near to revolution? Why, that would be Southern, wouldn't it? 

What is the general arrangement for the management of the Southern line? Govia runs the system on a day to day basis, under a contract from government. That is, this is not in fact a franchise, this is a management contract. One in which all revenue risk is carried by said government. Fares go to the centre, the agreed fee is paid for running the network.

In order to mitigate the outrage about the train system the civil services suggests expanding the management system applied to that part of the network which produces the most outrage.

Really, we're quite sure that this is unlikely to work.

What joy when telling the truth is politically unacceptable

An entirely reasonable contention is that if we're to try and work out what it is that we should do we must start from some mutually agreed set of facts. It would also be useful if those agreed facts were the truth of the matter. Not starting from this point is going to be piling error upon misunderstanding.

At which point what joy that telling the truth is now considered politically unacceptable:

Philip Hammond has declared that public-sector workers are “overpaid”, as a bitter cabinet war erupted over austerity.

At a heated cabinet meeting on Tuesday, the chancellor refused to lift the 1% cap on wages for public-sector workers on the grounds that they earn more than those in the private sector, along with generous taxpayer-funded pensions.

But Hammond left his colleagues thunderstruck at the language he used. “Public-sector workers are overpaid when you take into account pensions,” he declared. The chancellor then described train drivers as “ludicrously overpaid”.

The comments will fuel public anger that the Tories are out of touch with the public mood and will plunge Tory MPs into despair at the chancellor’s political tin ear. 

The point being that this is actually true. As one of us has described elsewhere recently, since 2002/3 public sector pay (not including pensions and other perks) has gone from roughly comparable to private sector, risen faster in Brown's boom years and fallen less since the recession. Yes, of course, this is after controlling for age, qualifications and so on.

It's also entirely true that public sector wages have fallen in real terms since the recession - but then so have private, the private by more. These are the facts of the matter. Only once we all agree them can we then start to have a reasoned conversation over what we should do next.

But what chance of that when uttering such truths is regarded as politically unacceptable? 

It's almost as if they've no clue what they're doing

Two months ago we had this:

The transfer of 1.6 million patient records from an NHS trust to Google’s artificial intelligence subsidiary was legally inappropriate, the Department of Health’s data guardian has said.

Google’s Deep Mind division and the Royal Free trust in north London agreed two years ago to collaborate in developing an app to diagnose acute kidney injuries in NHS patients. It works by immediately reviewing blood test results for signs of deterioration.

To develop the Streams app, the trust made available to Google patient data going back five years, including sensitive details of patients who had not been treated or tested for kidney injuries. 

Using NHS data to train an AI to make the NHS work better is terrible. Those damn yankees and their technical skills, who do the bastard septics think they are trying to improve that Wonder of the World that is our very own National Health Service? They'll be forcing the ICU patients to pay $50 for an aspirin soon enough what with their only for money health care systems!


NHS patients will receive pioneering treatments assessed by an artificial intelligence program under plans being developed by the government’s medicines regulator, The Times has learnt.

The system, a prototype of which will come online next year, is expected to markedly speed up the appraisal of cancer drugs and other therapies from months to a matter of weeks.

Ooooh! Using NHS data to train an AI to make the NHS work better is just lovely.

Scientists at Microsoft, University College London (UCL) and Cochrane, a non-profit group that compiles reports on medical evidence, are developing an AI that can weigh up new health studies for itself. 

Yea, even if the septics are involved.

It's as if the government doesn't know what it's doing, isn't it? And that cannot possibly be true about the NHS, an absurd thought. For we all know that it's so exquisitely managed that no system in the world comes near it.

For once we agree with Polly Toynbee

This is odd of course but stopped clocks and all that*. Polly Toynbee makes a useful and sensible point. The great adventure of expanding university access in the name of social mobility seems to be failing:

Now that a degree leaves students up to £69,000 in debt, with 70% never earning enough to pay it all back, maybe the surprise is that few school leavers have been deterred. A graduate still earns around 35% more than a non-graduate. But averages deceive. While the number from poorer backgrounds hasn’t fallen, dispiriting new research finds that even after gaining a degree from a good university, those from poorer backgrounds, without the connections or the money to take internships, fare worse in jobs.

The Paired Peers project, which followed a cohort of students from Bristol University and the University of the West of England, found that their family’s social class still counted most, whichever university they attended.

Sending 50% of the age cohort off to university in an attempt to shake up the social classes doesn't seem to work. OK, so, experiment failed, let's not do that any more, eh? Back to a more reasonable 10 to 15% of the cohort taking these academic courses, around and about the likely number who will benefit from academia rather than just a course, and that of course makes the problem of funding the system much more manageable.

In fact, Polly makes two sensible points:

The second great shock, which simply defies belief, is the 23% slump in the number applying for nursing places this year, the first year when nursing students pay full fees and lose their bursaries. That is despite spending half their training time providing useful service to the NHS. 

We made noises about this when it was first mooted, that nursing should become a graduate  profession. Disapproving noises as well. Not just because we're the sort of snobs we are but at least one of us has direct experience of people training under the old and the new systems. That new is not better than the old from direct observation.

Sadly, Polly won't manage to make the third and correct observation from this. Just as there can indeed be market failures so also can there be government ones. The entire joy of a market based system is that when a mistake is made those making it go bust and disappear from the scene. Government mistakes not so much - how difficult does anyone think it's going to be to reverse these two mistakes?

*It is left as an exercise for the reader whether we are or Polly is that ceased timepiece

Planning reform can be safe as houses

Over on Medium I've written up what I think is a politically-achievable plan for the Conservatives to get some real action on housing now that gives them something to campaign on at the next election.

In housing, the root problem is mostly the planning system restricting supply – not enough nice, big homes are being built, which keeps prices higher than they need to be across the board. You're not going to win by promising planning reform or anything like it — unlike rent controls, they don't sound good. But you might win if you can show that housing is becoming more affordable and more secure. 

I propose a three-pronged approach — allow densification within cities, and have it done on a bottom-up, street-by-street level instead of exclusively through massive new developments; let local councils capture some of the uplift in land values that comes when planning permission is granted to new developments; and introduce a 'long-hold' midway point between shorthold tenancies and leaseholds, which effectively confer ownership of the property:

"Private rents in the UK are some of the highest in the EU, and private rented households spend between 35% and 40% of their post-tax income on rent compared to a European average of 28%. This does not capture the second-order problem caused by expensive housing costs, which is that it is much harder to move to economically prosperous parts of the country where better jobs are, so people end up forgoing better jobs and salaries than they might otherwise get.

"Housing quality is also quite poor. New builds in England are some of the smallest in the developed world, and shared living areas are being turned into extra bedrooms in many rented properties, squeezing more people in. In 1996 54% of 16–34 year olds owned their own homes; now only 34% do. That’s a twenty percentage-point drop in twenty years. Over that period the number of renters in that age category has doubled from from 1.1 to 2.2m.

"Labour made this a major part of its election campaign. Economists nearly unanimously agree that rent controls do harm, but many voters do not realise the risks. Bans on lettings agency fees and making three-year tenancies the norm similarly sound appealing to people fed up with wheeler-dealer agents and having to find somewhere new to live every year.

"These are tangible policies that sound good on the doorstep. The Tory manifesto was vague on housing issues and offered no track record of improvement. The government’s housing policies were basically useless — they only seemed to be interested in getting people to own their own homes, but because they did little on the supply side, policies like Help to Buy mostly only raised prices and changed the distribution of who got houses, not increase the total number of homeowners."

Read the whole thing, and my previous piece on some other policies the Tories should be going for to win at the next election.

The case against the new corn laws

There was once a time when Peel’s abolition of the Corn Laws was regarded as an unqualified success, ushering in an era of free trade and prosperity hitherto unforeseen in human history. What was once taken as dictum, however, seems to be lost on the current generation of policy-makers. The Corn Laws, along with the general spirit of protectionism they represent, has once again become fashionable under the guise of the Common Agricultural Policy (CAP). Needless to say, there is no reason to suppose that a policy which was so disastrous in the 19th century, would be any less disastrous in the 21st. It is remarkable how similar, and how similarly conclusive, the arguments against agriculture subsidies remain. The case against this nefariously illiberal policy is made by simultaneously appealing to the needs of the consumer, the competitiveness of the producer, and the health of the international market more generally. The vote to leave the European Union on the 23rd of June offers the perfect opportunity for the government to repeal these new Corn Laws.

Subsidies are simply redistribution under another name – that of ‘protection’. By definition, subsidy requires the productive sectors to finance the unproductive sectors of the economy through general taxation. In the case of domestic agriculture, 1% of the employment market is financed by the remaining 99%. This is made all the more inefficient by the inequity of national contributions to the CAP, with the UK contributing £6 billion, while receiving half that amount in subsidy. The CAP does not even contain the one redeeming feature of redistribution – that of relieving the plight of the least fortunate. The CAP takes all the wealth of the whole of society (including societies poorest) and redistributes said wealth to a group of landowners, who predominantly belong to the upper middle classes. Moreover, the further effect of this subsidy is to inflate domestic food prices by artificially raising the barriers to entry for foreign imports. Regarding the discussion of the ‘cost of living crisis’ at the previous general election, removing domestic agricultural subsidies would be an effective way of pushing down the price of food without distorting the market.

The CAP does not even achieve what it purports to achieve: the goal of keeping the domestic agricultural sector strong. Rather, the effect of the CAP has been to starve the agricultural sector of much needed competition and free enterprise. Instead of farmers competing against one another in order to create the most efficient product in a free market, the sector is now make up of a rentier class, each competing for a subsidy from government (whether national or supranational). In 1984, the government of New Zealand gradually reduced all subsidies and import quotas on agriculture, with the process finally completed in 1990. The agricultural sector of New Zealand’s economy (which is far more important when relatively compared to the UK’s agricultural sector) consequently boomed, as fair and proper conditions were returned to the market.

Perhaps chief among the CAPs crimes is that it keeps developing countries poor, and in constant need of aid. Repealing the subsidy would enable imports, from African and South American countries in particular, to be sold at a competitive price in Britain. This would not only allow British consumers access to cheaper food, but increase the economic strength of developing nations. This would, in turn, allow western nations (the very nations which imposed the subsidy), to reduce their own foreign aid budgets towards these countries, enabling prosperity, and reducing embezzlement by corrupt officials in one fell swoop.

All that remains is for Theresa May’s government to emulate its Peelite forebears, by scrapping agriculture subsidies, without exception, over a gradual period of years. It may not be politically advantageous – it is in the nature of embedded interests to cause political trouble when their privileges are questioned – but the future benefits of such a policy would go a long way to cementing May’s legacy at a time when her premiership has yet to begin. Before the referendum on the 23rd of June, Paddy Ashdown attempted to boost the Remain campaign by threatening that leaving the EU would ‘open the door to cheap food world-wide’. Let’s take him at his word. 

It's time to privatise London's buses

London is home to some of Europe’s most congested roads. While the London Underground does a good job of speeding passengers across the city beneath the gridlocked streets, London’s buses provide what has to be one of the slowest and least convenient public transport systems anywhere in Europe.

However London’s bus network is often held up as one of the country’s finest. A walk down any major London street will usually involve passing several dozen red double deckers in the space of a few minutes. The TfL bus network covers every imaginable corner of the Greater London urban area with over 500 routes, theoretically making any destination in the city reachable for a travelcard or Oyster user.

It is often a revealing exercise, however, to look at how many passengers these routes are carrying. There have been proposals by Sadiq Khan recently to remove the several hundred buses an hour that use Oxford Street to make it a more pedestrian-friendly environment, but there’s a huge question around where these displaced routes will go. However, the question is never asked whether all these routes need to exist at all. Any amount of time spent watching the buses on Oxford Street will reveal that many of them are running close to empty.

Supporters of central planning and public ownership will often point to comprehensive network coverage as one of the advantages of having public transport managed by one authority. London is a textbook example of this; although the routes are run by private operators, they are specified and tendered by Transport for London, in stark contrast to the completely private commercial operation found virtually everywhere else in Britain.

Elsewhere in Britain, operators are commercially forced to respond to passengers’ needs. Intense services appear where demand is highest, while services disappear where demand is lowest. One consequence of this is that smaller communities lose their services, while another is that the routes that emerge are far more attractive to potential users switching from other modes of travel.

This isn’t the case in London. While the TfL network does succeed in providing a service to every community in the city, it fails in providing a service that responds in any way to demand. London’s bus routes are indirect, circuitous and painfully slow. The lack of speed is partly down to the traffic situation, but stops every few hundred yards and routes that rarely head towards their final destination are the main thing that makes a bus ride in London so frustrating. It also doesn’t help that the numerous buses themselves are a major contributor to the congestion problem.

It hasn’t always been this way. A limited amount of private competition was introduced in London in the 1990s, with operators like Grey Green bringing a splash of colour to the red monotony that otherwise prevails. Latterly, however, TfL has tightened its grip, creating a situation where private operators with ideas for new routes are prevented from starting commercial services within the city, even where demand for different routes is demonstrably present. The omnipotent authority has even clamped down on branding variations by its own tender operators, as though Metroline’s blue stripe or Arriva’s cream swish were somehow damaging the quality of service being offered.

Imagine for a moment what London buses would be like under completely private operation. Gone would be the slow red double decker carting fresh air around every backstreet it could find, taking the best part of an hour to cross a distance the tube can cover in five minutes.  In its place would emerge direct point-to-point services, picking up major destinations and responding directly to the needs of passengers. Competition on key corridors would drive up standards, while operators would bring in quality service brands like Stagecoach Gold and Arriva’s “Sapphire” that have proved so successful at bringing people out of their cars across the country.

Certainly, some less densely populated areas would lose out. High-income areas where bus usership is lower would see service cuts. That’s how supply and demand works. There are far better ways of providing connectivity to remote communities than a frequent empty bus service, wasting money and fuel on a vehicle that could be better deployed where that capacity is really needed. It isn’t realistic to expect every community to have frequent bus services, any more than it is to expect every community to have motorway-grade road connections.

But other communities could stand to benefit hugely. Take the likes of Camberwell, a gigantic hole in the rail and tube networks where buses are the backbone of public transport. Here, direct demand-responsive services could act as street-level extensions of the underground network, bringing huge improvements to one of London’s most poorly served districts.

The current state of London’s bus network is a sad reflection on the conflicted political ideologies that have shaped it since the 1950s. It’s sobering to realise that this is what remains of what was once one of Europe’s most impressive tram and trolleybus systems, destroyed as it was by a political drive to free up road space for the car. Now, again, the passenger is being left behind in the same spirit of political idealism.

Let’s move to a system that operates for the passenger, not the politician. 

Even the IFS is at it now

One of the things which puzzles people - we know this because people ask us - is how come there is all this shouting about austerity? Cash spending is up, spending as a portion of GDP is still, just, up over what Gordon Brown was spending pre-crash. So, err, what austerity?

The answer being that those complaining about it all are using a different measure. Well, obviously, they must be, if their measure is not according with reality. Even the IFS is in on this now:

Carl Emmerson, deputy director of the IFS, said: “An ‘end to austerity’ – as defined by no further net tax rises, benefit cuts or cuts to spending on public services – would require a very sharp change of direction. 

The point being that that's not the entire budget. A notable lack there is the interest bill for the public debt. Something which has risen rather a lot in recent years and which, as interest rates rise again is going to become ever more important. We don't in fact predict that this will be true but it is certainly possible that said interest will become an expense to rival that of the NHS (debt of 90% of GDP, interest rates up to say 5%? Could happen). And we do tend to think that when we talk about a budget then we should be talking about a budget, not just the nice stuff that people like, the spending upon themselves.

We've also seen a rather more economist's definition of austerity, whatever level of spending is below what would ensure full employment. That meaning that anything less than near infinite spending in 2008/9 being austere given the depth of that recession.

The answer to the basic question is that by our measure, total spending, there has been no austerity. You can indeed cook up measures by which there has been some. But the rest of us don't have to agree with the recipe you've used to do that cooking.