Universal services really aren't safe in their hands

Tweet

There are those for whom the words ‘communist’ and ‘Marxist’ are words which have no meaning other than as insults to be hurled against political opponents in the belief that they will spark all sorts of associations with the old Soviet Union.  So when Boris Johnson refers to Labour’s plans for a full fibre internet service to every home as a “crazed communist scheme”, it’s more than possible that he is giving little thought to the detail and is just seizing on another opportunity to paint Corbyn as an unreconstructed pro-Soviet socialist from the past.

It’s also possible, though, that even if that was the limit of his intention, the use of the word does reveal the way he thinks, because he’s far from being the only person on the political ‘right’ who believes that all services should be provided by private companies in a free market, and that universal provision by the state is indeed a step towards communism.  It’s a belief which underlies health politics in the US – a standard element of opposition to all attempts to extend public health care is that a universal service is a ‘socialist’ idea, and therefore inherently bad.  His comments on Labour’s broadband plans suggest that Johnson and his followers hold a similar belief that universal provision is ‘socialist’, and the only reason that they are reluctant to apply the same criterion to health care is that they know it would be a step too far for public opinion.

The basic idea behind Labour’s proposal – that a broadband service of a particular standard should be seen as something available to all – is one which makes a lot of sense in the world as it stands today; digital exclusion is an increasingly serious divide in society.  Whether the best way of achieving that is by nationalising the provider is another question entirely, and had the Tories come forward with an alternative proposal for achieving the same thing, one might be able to believe that they want to do something about that divide.  Dismissing the end because they oppose the means serves only to suggest that they are basically happy with the increasing divide.

Agreeing with the Tories

Tweet

Last week, the Tories in the Assembly returned to one of their all-time favourite themes – high salaries in the public sector.  This time, it was the health service which was the subject of their ire, and they seem to have a particular fixation about any salaries which are higher than that of the Prime Minister.  The Labour government responded in the traditional manner of those who support paying high salaries, talking about the need to ‘attract the best’ to fill the top jobs.  In some ways, this is almost the reverse of the position one would expect the two parties to take.  Traditionally, Labour would oppose high salaries, and the Tories would talk about needing to attract the best. 

I can understand that, for someone who genuinely believes that high salaries attract the best candidates rather than simply the greediest, capping those salaries at an arbitrary level (‘the salary of the Prime Minister’) would be a damaging interference in the employment market, and would lead to the people in the top jobs being sub-optimal for the performance of the relevant organisation.  It follows that the Tories cannot believe that the way to attract the best people is to allow market forces to operate (although I accept that that statement does discount the possibility that they might actually not want the best people to run public services anyway – but they couldn’t really want those services to fail, could they?).  And the reaction of the Welsh government suggests that Labour really do believe that paying higher salaries attracts better candidates, and that good talented people cannot be found at a lower price.

The good news in all this is that I’ve finally found an issue of principle on which I can agree with the Tories and disagree with Labour – I really don’t believe that there is a direct relationship between how much someone is paid and how good they are at their job.  When it comes to salaries of top earners, there is a distorted market in operation in which a self-perpetuating group of rent-seekers push salaries ever higher to serve, ultimately, their own best interests.  What I don’t understand, however, is how it’s possible to believe one thing in relation to the public sector whilst believing that the complete opposite rule applies in the private sector.  So perhaps I don’t agree with the Tories very much after all.

Supply and demand

Tweet Over the years I’ve sat in a number of meetings with health service managers and professionals who have patiently explained why there is no need for anyone to worry about reductions in the number of beds in our hospitals.  Their logic has always struck me as impeccable.  Treating more people in the community, shorter hospital stays, less invasive surgery – all of these should indeed lead to a reduction in the total number of beds required.

Logic, however, isn’t enough if there are underlying problems with the data and assumptions.  And if the starting point is not right in the first place, then simply moving the goalposts in line with changes in all the factors listed simply perpetuates any mismatch between total demand and total supply.  Sooner or later such contradictions will inevitably be exposed.

This report a week or two ago that 2600 routine operations were cancelled because of a “lack of beds” should come as no surprise to anyone, in that context.  What was a surprise however – even to a hardened old cynic like me – was the way in which health chiefs explained the situation.  Even more surprising is that they appear to have got away with it.

The problem, to listen to them, is not on the supply side at all – it’s on the demand side.  There aren’t really too few beds – just too many patients.  It’s not their planning and assumptions that are wrong – it’s simply that too many of us became ill last winter.  In short, it’s our fault not theirs.

The problem with dismissing the problems of last winter as some some sort of blip as a result of too many people becoming ill is that no proper action is taken to address the underlying mismatch between supply and demand.  And unless that is done, we can probably expect a repeat at some point in the future.

How on earth are those in authority getting away with this one?

Much ado about very little

Tweet

Later today, our legislature in Cardiff will be debating a motion of no confidence in the Health Minister.  Given the respective size of the party groups, it’s likely to be a close vote, but unless there is an element of “differential absenteeism”, it’s a motion which will not be passed.

There’ll be quite a lot of huffing and puffing as the various opposition AMs rise to their hind legs to express their outrage.  It’s at least possible that there will be an occasional instance of genuine outrage, but most of it will be manufactured especially for the occasion – or rather in the hope of getting a brief clip into the BBC report on the debate.

Ultimately, the vote is about one of those monumental irrelevances of which politicians of all shades seem so fond, but which are a real turn off for the rest of us.  Because they’re not debating the threat – whether real or imagined – to local hospitals, nor even the principle as to whether service configurations (the posh euphemism for changes to what hospitals do) need to be made.

No, they’re debating whether or not the government might have done what all known governments in all known countries have done on a regular basis – try to influence the conclusions of an external report to justify their own actions.  And the evidence that the Minister herself was involved, even if such an attempt was made, is rather less than flimsy.  It's a 'bubble' debate of classic proportions.

It’s just as well, of course, that they’re not actually debating the substance of any proposed or mooted changes to the health service in Wales, because the only thing that unites the opposition parties when it comes to the substance is opposition to what Labour propose - whatever Labour might propose.  (And, in the interests of fairness, I think we can say that were there to be a non-Labour Government proposing the same, or indeed any, changes, then Labour would be equally opposed).

Whilst the three opposition parties are all against Plan A, the chances of them ever agreeing on a Plan B are slim, to say the least.  (And that doesn’t only apply in the field of health care.)

In that context, one has to wonder about some of the calls recently for the three opposition parties to work more closely together in the Assembly.  To what end?  It might make for more exciting television news bulletins, and give print reporters something to write about as they try to hype up the drama around the at-best theoretical possibility of a government defeat, but what would it actually achieve?

The only obvious outcome that I can see is to confirm Labour’s narrative that everyone is either with them or with the Tories.  That certainly helps Labour electorally; and it may even help the Tories by painting them very clearly as the main opposition.  But it doesn’t obviously help either Plaid or the Lib Dems - let alone the electorate.  And it tells us little or nothing about any alternative proposals.

The hope of many of those of us who spent so much time and effort arguing for a new democracy in Wales was to build a different type of institution, not merely to ape the confrontational style of Westminster.  It seems, however, as though many of our AMs, aided and abetted by the media, who are pursuing their own need for something less anodyne to report, are intent on creating a Westminster writ small.  But even Westminster could find a better subject for a motion of no confidence than this one.

More than spin needed

Tweet

In Saturday’s Western Mail, Matt Withers turned his attention to the perennial question of changes to the delivery of hospital services in Wales, and raised some key points.  It’s a thorny issue, and it’s difficult to get to the right answer.

Politically, any attempt to remove services from local hospitals will be painted as centralisation, and is certain to stir local protests.  But, as Matt points out, there are serious concerns that the current situation is actually unsafe in certain respects, and that isn’t really a political issue.

It often looks as though the professionals themselves are split on the issue; whilst some express their fears about centralisation, others equally sincerely express their concerns about patient safety.

As far as I’m aware, no-one is suggesting that all hospitals in Wales should have a team of qualified brain surgeons on hand.  The annual number of cases simply does not require that level of provision.  Generalising from that, it is clear that there is, therefore, a willingness to accept that certain specialised types of care are best provided in a smaller number of hospitals which have the expertise and the facilities to cope with them.

Again, as far as I’m aware, no one is really suggesting that district hospitals in Wales should cease providing a good level of general surgery and medicine covering most of the illnesses which affect significant numbers of the population.

The problem is in drawing the line between the two.  Whilst we all want to be treated as locally as possible, how many of would really prefer to be treated by a team who’d never seen a case like ours, instead of by an experienced team which dealt with a number of cases each year, just in order to be more local?  Give me the expertise any day.  And that question is what should be at the root of the government’s case for change.

To read some of what the professionals and politicians are saying, the failure of the government to convince us that they’re drawing the line in the right place is a ‘presentational’ problem; all they need to do is find a better way to put their case and we’ll all be convinced.  (Or even, as the WM article suggested, simply find the right time between elections where they won’t suffer too much political grief as a result.).  I think they’re deluding themselves.

Against a background of previous attempts to centralise services, in what generally looked as proposals more motivated by financial considerations than by health care considerations, it should be no surprise to anyone that there is a good deal of suspicion about any proposals emanating from the government.  There have been previous proposals which were about centralising whole services rather than just the most complicated and unusual of cases, and it often appears as though those proposals are simply being recycled under a different banner.  They’ll need more than good PR to shift that perception.

Not so obvious

Tweet

On first reading, yesterday’s report in the Western Mail, that Wales’ health boards do not know how many patients are receiving radiotherapy treatment, nor what the cost of that treatment is, seemed quite ‘shocking’ or ‘staggering’ to use some favourite words from politicians’ press releases.  It seems inherently obvious that they ought to know such things, doesn’t it?  But then I remembered a dictum of one of my old science teachers – “that which is obvious isn’t necessarily true”.

Jumping from an inability to answer some very specific questions about the detail of expenditure on one particular type of treatment to an accusation of ‘financial ineptitude’ as the leader of the Lib Dems has done might make for good headlines, but doesn’t necessarily reflect reality.  There are, as anyone managing a large budget will know, many different ways of analysing expenditure in order to manage and control it; an inability to respond to a newspaper’s request to analyse it in one particular way does not, in itself, mean that there is a lack of control.

One of the challenges for those managing a large and complex organisation like the NHS is to ensure that they concentrate their attention on key information, and don’t get drowned in mere data.  Finding the right balance can be harder than it looks.  I don’t know whether they’ve got the balance right or not – and yesterday’s story gave me no help at all to improve my understanding.  The most that I can say is that there are some questions which the external auditors ought to look at to satisfy themselves that expenditure is being properly controlled.

What I do know is that ensuring that data is kept in a format which will enable any and every question to be answered on demand is not likely to be the most productive use of resources.  And those criticising the inability to answer this particular question seem to have complained often enough in the past about the numbers of bureaucrats and managers in the NHS.  Asking for more detailed record-keeping seems inconsistent to say the least.

Oscar Wilde described a cynic as “A man who knows the price of everything and the value of nothing”.  I don’t want a health service which simply ignores price issues; but I do want one which understands value as well.

Going their own way

Tweet

I confess that I quite enjoyed the sight of Cameron, Clegg, and their film crews being berated and told to leave by an angry doctor during their hospital visit yesterday.  There was a certain poetic justice in it, given that their visit was part of their efforts to sell their proposals to give doctors more power over what happens in the NHS in England.  ‘Be careful what you wish for…’ might just be ringing in their ears.

I’m not convinced that the much-trumpeted changes in the policy are as significant as the presentation of them might suggest.  The Conservatives want to present the changes as a result of listening to what people have to say, whilst the Lib Dems seek to present them as a Lib Dem victory within the coalition.  Labour of course simply want to be able to describe them as being a U-turn. 

The result is that all three parties have a vested interest in making out that the changes are significant – whatever the reality.  But the key principles – of extending the market approach and letting in more competition – seem to be unchanged. 

In that sense, the Tories have won.  They can always reintroduce a firm timescale later, and extend the degree of competition.  The Lib Dems have been bought off by being allowed to claim some sort of victory.  And Labour are left shouting on the sidelines, trying to oppose something which they’ve also described as being a U-turn from the original proposals.

It doesn’t affect us in Wales directly, of course.  But it is the biggest example yet that I can think of where the increasing divergence between NHS structures in Wales and NHS structures in England stems from a change made in England, rather than, as over the previous four years, from changes being made in Wales. 

It’s a clear case of ‘England going its own way on health’ (and why not, if it’s what they want), but I find it interesting that it doesn’t get presented that way.  It certainly would if it were Wales or Scotland introducing such changes.

Visiting the Doctor

Tweet There are those who argue periodically that the days of ideology in politics are dead and gone. In much of what passes for political debate, that often seems to be true. But I'm not convinced; there are plenty of issues where the underlying disagreement is really an ideological one; it just isn't presented in those terms.

Yesterday's news about a Labour-leaning think tank suggesting a £20 charge every time anyone visits the doctor is a case in point. It's presented as though it's merely a suggestion, an option, for addressing the budget deficit, but there really is an ideological disagreement underneath that.

There are, in practice, three ways in which we can pay for health care:
• We can pay for what we use at point of use;
• We can pay through an insurance scheme; or
• We can pay through taxation.

There is no necessary reason why the total cost of delivery or the total amount paid should be any different under those three potential models, but there is a huge difference in the impact on who pays, and how much they pay. Under the first, those who are ill most often pay the most, under the second, we all pay broadly the same, and under the third, payment is based on the ability to pay.

Whilst people can and do put forward practical arguments why one is better than another, or why we should mix and match elements of two or three of them, the argument at root is not a pragmatic one. Positions are taken on the basis of a belief about what is right and what is wrong – and if that isn't, ultimately, an ideological argument what is it?

I'm in no doubt that my own commitment to free health care – including prescriptions and visits to the doctor – stems from my view that health care should be universally available as needed without cost at point of use, with contributions being based on ability to pay. And I shall continue to make that argument.

Multi-tiered health

Tweet I'm not convinced that it's entirely fair to use Dan Hannan's words as evidence of some sort of secret agenda by Cameron to destroy the NHS, although some seem to have been trying to make that leap. I do believe that it is entirely fair to point out, however, that Hannan is far from being alone in his views, and that there are a number of people in the Tory Party who really do want to dismantle the NHS. And I suspect that their views are rather more widespread in that party than the official line would suggest.

What remains unclear is how much influence that line of thinking has within the party – and to what extent that would be strengthened by an influx of new Tory MPs if they win a number of additional seats at the next election. Will Cameron be able to make his own views on the NHS stick?

More worryingly, Hannan's outburst has led to a number of people who ought to be natural defenders of the NHS to start considering the idea of replacing a tax-funded service with an NHS funded through compulsory health insurance. I think they are wrong, for a number of reasons.

In the first place, a service funded by insurance payments would be a fundamentally different kind of service. It is a complete shift away from a service 'free at the point of use', since it would mean that each and every use of the service was accompanied by an invoice. The invoices would be sent direct to the insurance companies rather than paid by the individuals, which means that it might not look that different from the point of view of the patient, but it would represent a completely different approach to running and administering the service. It doesn't necessarily mean a full-scale privatisation of the NHS, but that would be the likeliest outcome for an organisation delivering services for which it then charges.

Secondly, funding the service through insurance premiums would not, of itself, bring one extra penny into the funding of the service. The only way of increasing the funding by such a move is if the total payments made in insurance premiums exceed the amount paid from general taxation revenue at present. And of course, they'd need to exceed that sum by at least the amount of profit to be creamed off by the insurance companies, just to stand still.

What it would do, of course, is to change the basis of payment from a tax system which has an element of progressiveness about it (the amount paid depends at least in part on ability to pay) to a system which takes no account of ability to pay, except in the minority of cases where a basic safety net provision is put in place.

The third reason is that, even with a state-guaranteed minimum level of provision for the most needy, different people would have different levels of cover bought from different insurance companies. We would have at least a two-tier – and probably a multi-tiered – system of provision of health care, based not on health need, but on the level of premium paid.

In effect, the most well-off would pay less for a better standard of health care than they get currently; whilst the less well off would pay more for a lower standard. The Hannans of the Tory party know this – and also know who their target audience is.

Messenger survives shooting

Tweet I spent much of yesterday at two consultative meetings on the reorganisation of Community Health Councils; one in Pembrokeshire and the other in Carmarthenshire.

The Pembrokeshire meeting was by far the better attended; not just in terms of numbers, but also in terms of people from outside the CHC itself, representing the public and a range of other groups. It was also the most fiery – there were times when I began to wonder whether the civil servant sent to explain the Assembly Government's proposals and listen to the views expressed would escape with his life. But, in fairness to him, he was only the messenger.

There is real concern in the county - mirrored in Carmarthenshire, although one has to say rather less forcibly expressed – about what looks like a more centralised and less locally accountable new structure for the CHCs. And it's entirely understandable. Pembrokeshire CHC was right at the heart of the battle against the closure of Withybush Hospital in 2006/2007, and the feeling locally is certainly that a more centralised structure would not stand up for local interests in the same way.

The Health Minister, Edwina Hart, clearly feels that the current structure is not working as she would like it to operate, and will be even less fit for purpose in the new NHS structure with a reduced number of Health Boards and the abolition of the Health Trusts. But what is currently proposed simply won't do in the eyes of local people.

There are alternatives, such as a looser federation which maintains the current county identity but allows the three CHCs in the Dyfed area to come together to express a common view as well. I very much hope that the Minister will listen carefully to the views expressed locally, and change the proposal as a result of the representations received.

Pills and Potions

Tweet I'm not convinced that yesterday's story about numbers of items prescribed actually tells us anything meaningful about the effects of the introduction of free prescriptions in Wales. Without a good deal more background information on trends before and after the introduction of the policy, and a lot more detail on what is being prescribed to which categories of patients, I don't see how anyone can conclude that the policy is a "disaster" as some have been quick to claim.

That lack of precision has not prevented those who oppose the policy from jumping to conclusions, of course. It's the old politician's motto - why let mere facts get in the way of a good press release?

The basic case for free prescriptions – which I entirely support – has always been that medicines are an integral part of health care, and that health care should be free to users at the point of demand. The chief argument of opponents has always been that some people can afford to pay for their medicines and that would free up money for other purposes; but I've never understood why they apply that logic only to prescription medicines. Why single out just one aspect of health care for means testing, and why choose this particular aspect?

Some people can afford to pay for visiting the doctor; some can afford to pay for their operations, or their physiotherapy, or their nursing care. Why do some politicians argue that all of these should be free, but medicines should not? I've never heard any of them explain why medicines are so different from all other aspects of health care that they should be paid for whilst everything else should be free.

And since the objections to free prescriptions generally come from the political right, I wonder whether this isn't the thin end of the wedge for people who really believe, but don't admit it, that large swathes of our health services should be means tested rather than free, in order to give yet more tax cuts to the better-off.

That doesn't mean that the policy is entirely without its problems; some people do now visit the doctor unnecessarily to get a prescription for over-the-counter medicines. But some people also visit casualty departments unnecessarily for trivial injuries – isn't the effect the same? If there are cases where the system is being abused, I'd prefer that we attempted to deal with the abuse rather than re-introduce means-tested elements to the health service.