Tuesday, 10 January 2017

Has Jeremy Hunt opened a can of worms or is he being disingenuous


In November 2009, I gave my inaugural professorial lecture at Nottingham Business School with the title “The future of UK public services”. This was just at the start of the era we now term “austerity” and one of the points I emphasised was that we shouldn’t see the situation pertaining, at that time, as a “blip” with normal service resuming shortly, once significant economic growth returned to the UK economy. As so it has proved to be. Austerity is still with us and seems likely to remain with us for the foreseeable future.  

One of the things I emphasised in the lecture was that we should avoid what I termed “death by a thousand cuts” or “salami slicing”. Instead, I said that we should recognise the current situation as a discontinuity from the past and one, which has led to what I termed a social and economic watershed in our history. I emphasised that we should address the problems of organising and funding public services by considering the questions shown below and having a vigorous public debate about the issues raised. It would also help if there could be some sort of political consensus among the major particular political parties on, at least, some of these issues. My questions were:

  • What should be the future role of the state in the provision of public services
  • What should be the limits of its involvement?
  • What should be individual and collective responsibilities in relation to specific public services?
  • How should public services be paid for in the future?
  • How should public services be organised?
  • What should be the balance between the private and public sectors of our economy?
  • To what extent should the private sector be involved in public service delivery?
    Not surprisingly, seven years on from my lecture, none of the above has taken place. We have had no public debate on these issues and we have had endless salami slicing coupled with a public relations exercise designed to give the public the idea that cuts were not taking place at all. I have lost track of the times I have heard something on the radio or TV whereby a particular vested interest is protesting against a cut in a service which they hold dear. Up pops, a Government Minister to explain that no such cut is actually taking place and indeed the government is providing more funding from some special funding pot it has established. What should be noted, however, is the heroic efforts of many public services (especially local government) to minimise the impact of the cuts in their funding base.
    Oh, and we have had no political consensus on any of these issues. In fact, the main opposition parties still cleave to their Father Christmas policy whereby we should fund more public expenditure from more borrowing while forgetting that we have to pay interest on that borrowing and repay the debt at some future date.
    At the start of 2017, it does look as if the chickens are now coming home to roost on public expenditure. In late 2016, we had the crisis in adult social care, which has been deferred for 18 months or so by some short term funding. Today, we see NHS services creaking under the strain especially in accident and emergency (A&E)  services. In the new financial year, we can expect huge amounts of public and professional concern about the financial situation schools will find themselves in 2017/18. In addition, the Ministry of Defence will face its usual problem of too many commitments and too few personnel and assets to meet them.
    However, something happened yesterday, which might give hope. Yesterday, the Secretary of State for Health made a speech in the context of the accident and emergency crisis whereby he stated that the four-hour waiting time target for A&E patients to be seen would exclude patients who turned up at A&E with minor ailments. In response, Jonathan Ashworth, the shadow health secretary, said: “Is he now really telling patients that rather than trying to hit the four-hour target, the government is now rewriting and downgrading it?” I would suggest that in making this change Hunt is explicitly recognising that the NHS cannot be all things to all people at the same time. Once we start looking at A&E we can start looking at other health services and start questioning whether other targets should be modified to recognise differences in priorities and importance of the services involved. Going on, we can look at other public services and start questioning whether they are all as important as one another or are some more important than others.
    Where Hunt becomes disingenuous, however, is his attempt to pass the blame for patients with minor ailments presenting at A&E on the patients themselves. Last year, I was involved in some research looking at how the pressures on a major city A&E unit could be mitigated. It is quite clear to me that nobody in their right minds wants to be in A&E waiting for 4,5,6+ hours. They are there, either because they have no alternative access to treatment other than A&E units (where they will be seen eventually) or there is some alternative treatment they could access but nobody has told them about it. Indeed, after 35 years’ experience of the NHS I found myself in something of a predicament in that I had a minor problem with a finger, which wasn’t clearing up despite self-treatment. I showed it to a GP friend and asked her if I should go to A&E to have it looked at. Her response was “don’t be so stupid, go and see your GP practice nurse”. Now I didn’t know that this was an option and indeed, until I try it, I am not sure it is an option. I suspect I will first have to see my GP on a non-urgent appointment, which could take three weeks and then wait another couple of weeks to see the practice nurse. Better to go and wait in A&E and get it done.
    The morale here is that the A&E crisis can be easily be involved by re-designing services in such a way that patients can access services for minor problems  reasonably quickly and that those patients are made aware of this.
    If we don’t change anything, nothing will change.

Thursday, 15 December 2016

The rail strike puzzles me


The rail strike puzzles me. Ostensibly, it seems to be to do with whether drivers or guards should be responsible to ensuring the doors are shut properly and there are no safety issues involved. However, this can’t really be the case and there are much greater titanic battles going on between the companies, the unions and government.

I can well remember the old British Rail, which was a nationalised industry until privatisation in the years 1994-1997. After privatisation, the rail industry comprised Railtrack (as it was called then) which managed the infrastructure and numerous rail companies who provide the train services and owned the rolling stock. However, as a frequent rail user, I never really saw any great change and I still refer to the industry as British Rail. Why do I sense little change has taken place in the UK rail industry and why do I still call it British Rail. Well for example:

  • The trains still often run late and communications of these delays is often poor
  • There is still a reliance on paper tickets – Transport for London introduced Oyster cards some 13 years ago
  • You can still get fined if you board a train without a ticket even though there is a ten minute queue at the ticket office and you would miss your train. Oh, and I once saw an automated ticket machine which was out of action for a month.
  • The conductors/guards or whatever they are called are still of very variable quality. Some are helpful while some are not. Some provide information over the intercom while some do not.
  • The fare structure is totally incomprehensible as it always was
  • Some days you get on the train and find the buffet car is closed because “the chef is ill”. I haven’t yet seen an aeroplane, which left without refreshments being available. Perhaps airlines employ healthier staff
  • The waiting room at the stations remain locked until 6am or 7am while passengers (including those with first class tickets) shiver on the station waiting for a 5:30am train
  • The train is in the station with the staff locked inside while the passengers shiver on the station platform
  • The ticket prices are astronomically expensive to an extent which shocks people from other countries

I read somewhere that much of the conditions of service of rail employees date back to the formation of British Rail in 1948 and perhaps even earlier. The points I have made above (and others) seem to point to an industry, which hasn’t really changed much in terms of working practices for almost seventy years. By way of contrast, in 1994 the UK telecommunications industry was privatised and BT (as it is called to day) is unrecognisable as the nationalised industry it was some thirty years ago – so great is the change that has taken place with regard to technology and employee working practices. This sort of revolution seems to have passed by the rail industry.

This seems to me to be the real cause of the strikes. An attempt to move the rail industry from the mid-20th century and earlier, to the 21st century. This looks like a prolonged battle, which can only end in one way. However, who will be the casualties.

 

 

Monday, 28 November 2016

Social care of the elderly: Time for action not words


The phenomena of ageing populations is well known as a UK and an international challenge. The increases in the proportions of the population which is deemed elderly (65+) and very elderly (80+) are forecast to continue and it is said that one in four children born today will live to be 100.  

The aging population has implications in a number of areas such as: health, housing, labour supply to the economy, pensions etc but one of the biggest challenges concerns social care for the elderly. The provision of social care to the elderly can range from giving a small amount of support to elderly persons living independently in their own home to the provision of 24 hour residential care and nursing care. As the numbers of elderly and very elderly increase so does the volume of social care needed increase.

While this has been a looming issue for many years, what has exacerbated the situation is the application of financial austerity measures to public services and, in particular, to local authorities who have primary responsibility for the delivery of social care to elderly persons. In the last few weeks, media reports have commented on some local authorities being close to collapse because of the funding pressures of the ageing population.

What is certain is that we cannot go on as we are. The well-known Barnet Graph of Doom shown below indicates that if nothing changes then by 2022/23 the costs of adult social care and children’s services will exceed the council’s total budget with nothing left for all the other services. Clearly this cannot happen but it does indicate the grave problem facing local government

http://inlogov.files.wordpress.com/2012/05/game-graph-2.jpg

The simple aim must be to reduce the proportion of the elderly going into residential (or nursing care) and increase the proportion receiving other forms of social care such as homecare, sheltered housing etc. This is not just about the costs involved but the feasibility of delivering increasing volumes of residential care when considering

·         The current instability in the residential care market which does not seem likely to disappear in the near future. Indeed last week it was reported that several private providers were planning to withdraw from the residential care market because of a lack of profitability on current tariffs

·         The possible problems with the supply of social care labour particularly as a consequence of BREXIT. A large proportion of social care is already provided by Eastern Europeans who may not remain in the UK

So what is to be done? Well in the short term, the only option appears to be for the government to provide additional funding to keep the ship afloat until a wide range of measures can be implemented to provide a greater degree of stability. To achieve this stability, in the longer term, there must be substantial changes in the way adult social care for the elderly is organised, funded and provided and in the interface between health and social care. This is especially true since austerity is set to continue for the foreseeable future.

Significant change is required in many areas and unfortunately, there are no easy options since all of the “low hanging fruit” has already been picked in the early years of austerity.  What is being talked about here is a complex and potentially expensive exercise which needs to be examined and evaluated carefully – one size will not fit all. The change process involved will, undoubtedly be difficult but it cannot be relegated to the “too difficult” box. This fact must be widely communicated, among staff, services users and politicians in that if we don’t address these issues we face disaster – do nothing is not an option

Based on work I have done recently, I suggest the changes required are wide ranging and will cover the following:

Housing

Firstly, social housing. In shire counties adult social care for the elderly is an upper tier responsibility while housing is a responsibility of the lower tier. The planning for the housing needs of the elderly is not always done well and often the districts within the county have different views. Improved co-ordination of public housing policies for the elderly must be undertaken. This should not be read as meaning that planning the housing needs of the elderly is always done well in unitary authorities.

With regard to private housing, it must be recognized that many elderly people have the financial resources to purchase a property suitable for their needs. Hence, there is a need for the local authorities to work more proactively with the private housing providers regarding housing for the elderly

Enhanced Prevention

Many elderly patients suffer a crisis and end up being admitted into an acute hospital and from there go straight to residential care – probably after blocking acute beds for several weeks. The key is to reduce the impact of these sorts of situations with the aim of keeping elderly people in their own homes

There is evidence that this can be mitigated by major reforms of health and social care services at the local level. This would involve a combination of

·         The strengthening of primary care and an enhancement of the role of GPs

·         The reconfiguration and strengthening of intermediate care of the elderly through the development of community based clinicians acting as a single point of access to a range of services, as a means dealing with the crisis and returning people to their homes.

However, these changes do not require major policy announcements from central government or the creation of special funds which are administratively difficult to access and too small to make a difference. What is needed is leadership and vision at the local level and the development of good partnerships between the various bits of the NHS and local government.

However, the process could be assisted by changes to the funding mechanisms of health and local government which often work against such collaboration and not for it. Currently, commissioners end up paying NHS Trusts to keep elderly patients in acute beds because there is a lack of funding or capacity to move them into social care which would free up the acute beds. Surely, it is not beyond the wit of man to devise funding mechanisms to overcome these difficulties.

Changing service paradigm

To a large extent, the existing paradigm of social care comprises a number of features including the view that elderly people need ongoing support and that the professionals know best. There is a need to shift social care services for the elderly to a new service paradigm more appropriate to the challenges of the future and to reshape existing services in line with this paradigm. In particular, while some people will need ongoing support, other elderly persons need to be empowered and given confidence to maximise the extent to which they can look after themselves, at home, with minimum support. This requires a major change in the skills base and outlook of many service professionals and will need to be reflected in professional training regimes

 

The use of technology

In the private sector, information technology has revolutionized the way in which companies do business. Just think about the growth in online shopping and the decline in store shopping.

While social care for the elderly will always require some degree of personal human contact there is considerable scope for using technology in a variety of ways to support social care of the elderly (see http://www.kingsfund.org.uk/publications/articles/eight-technologies-will-change-health-and-care). Hence there is a need to be pro-active about the identifying the potential for using this technology in delivering services to the elderly (taking account the points made above about changing the services themselves) and for having a robust operational and financial plan to put this into effect. Piecemeal approaches will probably fail to have major impacts.

Utilising spare capacity

There is a need to utilise whatever spare capacity can be found to support social care for the elderly at little cost. This could involve a number of approaches including:

·         Using other public service professionals (such as firefighters) who have spare capacity because of the emergency nature of much of their work and who could provide some support to elderly persons. Some fire authorities have already made great strides in this area but there may be other possibilities to be explored with regard to ambulance and police services

·         In developing countries, in Asia and Africa, social care for the elderly is rudimentary on non-existent but the population is ageing in a similar manner to that of developed countries. For financial reasons, one of the few options available to these countries is to stimulate voluntary support capacity in cooperation with third sector agencies. Similar approaches might be enhanced in the UK but would need some funding support in order to regulate and train the voluntary support workers

Implementation

The key thing to realise is that what is described above must be seen as a holistic package and a journey not a pick and choose exercise. Thus it must be recognised that all of  what is described above (and more) has three major implications:

·         A need for political buy-in

·         A need for significant financial investment up front to reduce downstream costs in the years ahead

·         Recognition that these changes involve a significant management of change effort which has both financial and managerial implications

In turn, this requires a strong focus on a number of key things

·         Robust project evaluation to identify which approaches are likely to succeed

·         Effective project management to achieve successful implementation

·         Good financial planning and forecasting to ensure that there are not cost overruns

·         The need to find funds from existing resources in order to reinvest in new services. I really believe that this is something that public authorities need to do themselves rather than rely on hand outs from central government which are often administratively complex and have too many strings attached to make it worthwhile.

·         The need to ensure savings from the rationalisation of existing services are actually realised. To fail to do this destroys the rationale for the change

·         A recognition of the need for major management of change programmes

 
Conclusion
While not everyone will agree with everything I have had to say on this matter, I think everyone will agree that it is imperative that action is needed. Popular culture has it that the Emperor Nero fiddled while Rome burned down. I want to argue that it is incumbent on local authorities and NHS organisations to rise to the challenges themselves and not wait for central government to play their fiddle.

Wednesday, 26 October 2016

Heathrow: A triumph for vested interests over rational policy analysis


Well, finally, we have had the news that the Government is to back the construction of a third runway at Heathrow Airport. However, why all the surprise? After fifteen years of debate with various sorts of analysis, inquiries etc two things should have been blindingly obvious:

  • The development at Heathrow would go ahead
  • It would probably be the wrong policy option

In future, this will probably be a case study for students of public management in how not to do public policy analysis. I have little doubt that the HS2 development, costing endless billions of pounds, will also go ahead and that too will be another such case study.

Basically, Heathrow is a triumph of vested interests over rational analysis.  The figures show that 70% of flights are taken by 15% of the UK population. Nor is this to do with the average family taking flights to Spain, Greece etc for their annual holiday. Instead, it is to do with celebrities, politicians, multi-millionaires, business people etc who want to jet off to the far corners of the world and wish see such a vanity project go ahead. Even if the project does ever go ahead (which is not certain) then it will probably be double the budgeted cost and three years late coming on stream. Similar issues apply to HS2.

What was the problem with developing capacity at regional airports in the UK and spending the money improving public and private transport links between the city and the capitol. Well, some years ago, somebody introduced me to the idea of perceived distance. This meant, for example, that somebody from London perceived the distance from London to Brighton to be greater than a Brighton person perceived the distance from Brighton to London. I began to notice that when group meetings were held in (say) Birmingham, London based people asked for a start time of 10:30 but if the meeting was in London, they expected Birmingham people to be there by 9am. Now while improved transport links could make the journey from Birmingham Airport to Central London to be only slightly longer than from Heathrow to Central London this would not suit the celebrities, politicians, multi-millionaires, business people etc. They don't want to catch public transport - they want to be picked up by chauffeured driven cars which means arriving at Heathrow and not Birmingham. Also, they would avoid having to visit the provinces, and seeing how the "oiks" live. Let’s keep it all in London.

Some years ago, I wrote a piece entitled “The problem is London” which highlighted the gulf between London and the rest of the UK in many areas of life. The Heathrow example shows nothing has changed.

BREXIT represented a situation where the huddled masses were able to express their opinion without it being vetoed by the London elite. Not surprisingly, the population of most of England and Wales voted in a completely different manner to the population of London. No doubt it was because the EU was seen as a good thing for London but not such a good thing for the rest of the country. Whether BREXIT will change any of this remains to be seen.

Wednesday, 29 June 2016

BREXIT: An opportunity to re-balance the UK economy


Some years ago, I wrote a paper entitled “The problem is London”. In this paper, I argued that London dominated the UK: demographically, politically, economically and culturally to an extent not seen anywhere else in the developed world. I wrote other pieces on a similar vein, in particular, one of which argued that the growth in support for Scottish independence was driven, largely, by hostility to London.

The domination of London in the UK has hugely detrimental effects on the rest of country and leads to the concept of the two nations – a prosperous London (and the South East) and an impoverished rest of the country. While this is an oversimplification (since there are pockets of affluence and poverty in any region), the reality is that London is ahead of the rest of the country in terms of income, wealth, health, employment and virtually any other indicator you can name. This is also exacerbated by the dominance of the London based financial services sector on the rest of the UK economy. In another paper published in 2010, Roger Latham and I pointed out the dangers of this unbalanced UK economy both in terms of geography and by sector.

This point has been only too clearly illustrated by the huge divergence in voting patterns between London and the rest of Wales and England. In London 60% voted to remain in the UK while in the rest of England and Wales the figure was only 47%.

We now see scare stories that BREXIT will impact negatively on the London based financial services sector and may lead to significant job losses. At the same time, I see quite a bit of optimism among small-medium enterprises (SMEs) that freedom from EU bureaucracy coupled (possibly) with greater interest in SMEs by a UK government traditionally more concerned with the London financial sector.

It suddenly struck me that perhaps BREXIT will provide the UK with an opportunity to re-balance its economy in such a way as to reduce the over-domination by London and the City. The decline in financial services in London may be an unavoidable consequence of BREXIT but this might be mitigated by a strong focus on SMEs across the UK. It is not always realised that in the UK, SMEs:

  • make up 99.9% of total number of businesses in the UK
  • provide 59.1% of all private sector jobs
  • generate 48.7% of private sector output

If a policy of growing the SME sector were successful, it would automatically re-balance the UK economy to some extent.

However, this will not be easy. The UK (and indeed the EU itself) have a poor record of SME productivity, which lags behind that of SMEs in the USA. This may, in part, be to do with EU bureaucracy but there are other factors at play. Last year the Government published, its productivity plan which outlined a number of wide ranging initiatives to improve our productivity record. While such initiatives are to be welcomed, I still have a feeling that the main driver of productivity concerns the quality of leadership and management within the SME itself.

Although the Government has published a productivity plan, it remains to be seen whether it will follow through, with gusto, what it has proposed. Perhaps it is time to end the love affair with the City and place a much greater focus on SME growth and sustainability.

Monday, 27 June 2016

Labour and the EU negotiations: Keeping an eye on the ball


Throughout the Referendum campaign, the Remain camp managed, with varying degree of success, to paper over many of the significant differences between them concerning the EU. While most of the Labour and the Conservative parties supported Remain, the reality is that many in the Labour Party will have a very different view as to what the EU should look like compared to many parts of the Conservative Party (especially those who may be in senior Government posts). Hence, the refusal by Jeremy Corbyn to appear on a platform with Conservative speakers

The campaign is over and both main parties will now be looking at the potential outcomes of the Brexit negotiations from their own political and ideological positions. This negotiation process will be long and tortuous and will probably involve the passing of UK legislation in many different policy areas. However, it is the Conservatives who are in government and it is they who will drive the negotiations, while the Labour party will have very much a watching and commenting role.

Unfortunately, the Labour Party seems to be engaged in civil war with no real idea where it will all end. This poses the great danger that it will take its eye off the ball in relation to the Brexit legislative programme. This is dangerous because the role of effective opposition is very important to ensure the new legislation is adequate and that it protects the interests of Labour voters. Political vanity cannot not be allowed to interfere with this role.

When Jeremy Corbyn (or whoever hold the Leader’s post) reconstitutes the shadow cabinet in the aftermath of the mass resignations, how about appointing a senior person (with a supporting team) to focus on the Brexit legislative programme going through Parliament – a shadow spokesperson on the EU. Better this than having it spread out across several different portfolios. Should the person involved be a Remain or Leave person? It doesn’t really matter provided they have an eye for detail and the tenacity to follow though points of concern. Is there another Robin Cook out there or perhaps an experienced barrister?

Friday, 24 June 2016

The EU referendum result: A second referendum?


Well the EU referendum is over. The votes are counted and the decisions made. What can we conclude? Well, not a lot if we are wise, particularly with regard to our membership of the EU? There are too many large vested interests in our society, and in the EU itself, which will not just go away and will not take this result lying down. The conspiracy theorists among us expect them to find ways and means to circumvent BREXIT.  

The EU seems keen for the UK to invoke article 50 (which starts the process of withdrawal) as soon as possible. However, we also hear talk, among some politicians, about “taking our time” and having a process of “informal” negotiations with the EU prior to taking this irreversible step.

I suspect that UK withdrawal from the EU will have a bigger negative impact on the rest of the EU itself than on the UK. Hence, I see such negotiations as a last chance for the EU to get serious about reform and give the new UK prime minister something to show the electorate in preparation for a possible second referendum. This time around, the prime minister can make it clear to the EU that if serious concessions are not obtained then UK withdrawal must happen whatever the cost to them and us. The EU Commission itself may wish to be stubborn and stand on its pride but it is up to the member states (especially the East Europeans) to make it clear that is they who are the EU, not the Commission.

If there is something substantial on offer then maybe a second referendum will be the way out. However, the EU needs to remember that the UK is the second biggest economy in the EU, a major contributor to the EU budget and the strongest military power. When Russian bombers are invading the airspace of the Baltic countries, the RAF provides the interceptor jets to dissuade them from going any further. What would happen if these jets “were no longer available for operational reasons”? If the EU wants to play dirty then the UK can play dirty too.

So in advance of a possible second referendum in a few years’ time, what else can we learn and what might be done in certain areas?

  • London and the rest – several years ago, I wrote a piece entitled “The problem is London”. This outlined the over-bearing influence of London on the economic, social, political and cultural life of the country a scenario not seen elsewhere. The consequences of this are clearly shown in the huge disparity in the Remain vote in London compared to the rest of England and Wales. The culprit here is the metropolitan elite (aided by the London media) who have tried for decades to force their values and views of the world on the rest of the country and have ignored issues which are most relevant in non-London communities. Their inability to understand the difference in lifestyles outside of London and the problems faced in places like the Northeast, the Midlands and Merseyside have meant a growing divergence in views, between London and the rest, about what is important in the UK. One of the pet projects of the elite has always been UK involvement in the EU a view which has now come unstuck. Something has to be done about this state of affairs such as, for example, English devolution, massive regional investment, a large number of seats in the House of Lord reserved for people living outside of London etc.
     
  • The future of the Labour Party – the vote suggests to me that the views of many parts of the (London dominated) Labour Party are just completely out of kilter with the views of people who traditionally support Labour.  In Wales (where I live), many party workers were shocked by the amount of resentment to the EU in Labour strongholds like the Rhondda and Ebbw Vale. I am sure similar situations will be seen in other Labour strongholds. I am also sure that research into this issue will show Labour voters saying that the party is too obsessed with issues such as: Trident, Syria, immigration and minority rights etc and not interested enough in bread and butter issues like housing, schools, poverty etc that are their concern. In the 1950s, the late Anthony Crosland wrote the famous book The Future of Socialism that became the Labour bible for decades. If ever there was a need for a new 21st century Labour bible, it is now. Once again, I am afraid there is a need to reduce the malign and over-bearing influence of London on the Labour Party nationally and its policies.
     
  • The Conservative Party – if Remain had won, I imagine there would have been ructions in the Conservative Party about the way David Cameron conducted the campaign. He had already alienated large swathes of his party over the introduction of gay marriage a policy that was anathema to many party members. He got lucky with the unwise Scottish referendum and then chose, unwisely, to placate his party with an EU referendum. Then he enraged them again with, in their view, the biased and mendacious way he led the Remain campaign. However, he will be gone soon and maybe George Osborne with him. I suspect Boris Johnson is too polarising a character to lead the party in this environment and a calming influence is needed. My money would be on Teresa May who while showing loyalty to Remain during the campaign made it clear that she was not at all happy with the EU as it is. Such a calming influence is needed to bring the two strands of the party together.
     

These are early days in the post-Referendum era and to quote the famous phrase, this is probably the end of the beginning not the beginning of the end