Tuesday, 28 April 2015

The future of the NHS looks grim

In every general election in recent years, the financial situation of the NHS comes pretty near the top of the list of concerns among voters. The 2015 campaign is taking place against a backdrop five years of financial austerity impacting on public services. Although the NHS was deemed to be “protected” from the pressures of financial austerity, it was left with a tiny amount of growth in resources each year and was also given a target of making £22 billion of efficiency savings over a four year period. This contrasts sharply with the first 62 years of the life of the NHS when it received substantial increases in funding each year (even if the voters weren’t always aware of this). Not surprisingly, the NHS is now really feeling the strain.
Now the former chief executive of the NHS, Sir David Nicholson, has thrown a hand grenade into the election campaign with his outspoken comments about the financial situation of the NHS. Among his comments were:
·         The NHS has a substantial financial problem, particularly in the hospital sector. The scale of the problem is probably bigger than the one Sir David inherited in 2006 on becoming NHS chief executive, when the health service had accrued a £1bn deficit under a Labour government.
·         Politicians of all parties are talking about providing extra health services when there is already a huge  "financial hole" in NHS finances
·         The planned NHS efficiencies of £22bn are a "big ask" for the NHS and failure to achieve them would lead to "managed decline" of the NHS with patients waiting longer for treatment.
·         The coalition government's NHS reforms were a "surprise" and a "significant distraction"
Now many of the points raised by Sir David have been known, for many years, by those of us in the health business who have written much on the subject of NHS sustainability. What is so incendiary about Sir David’s comments is that not only is he one of the most respected health service managers of his generation but he was also the man in charge of the NHS over most of the life of the coalition government and was responsible for such things as the savings targets (known as the Nicholson targets) and the NHS reform process. For him to be saying these things now demolishes a lot of the credibility of government health policy since politicians can’t go around saying things like “he has mis-understood what we were doing” when he clearly did understand.
In the light of these comments from Sir David, what are the political parties putting forward in their manifestoes about health policies. Well, we see a number of sensible (and some not so sensible policies) but the dominant issue is the funding of the NHS where there seems to be basically a competition between the political parties to see who can promise to spend the most extra money on the NHS. It has to be said of course that this is money we haven’t got since, for several years to come, we will still be borrowing tens of billions of pounds each year to plug the hole in public finances and this borrowing will have to be repaid by our children and grandchildren who will bear the cost of our extravagance.
Fundamentally, the current NHS model of comprehensive service provision, free at the point of consumption and funded from taxation is financially unsustainable in the short term and the longer term. The various political party promises to find more money for the NHS are predicated on the UK having decent levels of economic growth (which will generate higher levels of tax receipts) but this may not happen. On the same day as Sir David made his comments, the IMF expressed scepticism about the future economic performance of the UK and the availability of tax receipts to finance the growth in public services such as health.
It is sometimes said that the British aspire to Scandinavian (high) standards of public services on the financial base of US (low) levels of taxation. This can’t work and it is misleading to suggest that the circle can be squared through the generation of “efficiency” savings which, as Sir David suggests (and I agree) are not going to happen. We have to make a choice of higher levels of taxation and/or higher levels of private financial contributions. What is really needed is some form of party political consensus about the best way forward for the NHS instead of this ongoing competition to spend more public money which we don’t have. This means looking, with an open mind, at alternative funding options such as; charges, health insurance models (which operate perfectly well in other European countries) and earmarked taxes. However, the chances of this happening in the heat of the election campaign are approximately nil. Hence, whoever wins the election, we need to be prepared for the inevitability of such things in the NHS as longer patient waiting times, cuts in services, freezes on staff numbers and deteriorating buildings.
In the light of the above comments, it seems to me that irrespective of who wins the general election, the future for the NHS looks grim. However, I would be surprised if political behaviour has changed much by the time of the next election.

Monday, 9 February 2015

Unsustainable health systems

At the current time, the state of the National Health Service is perhaps the most controversial theme in the ongoing general election campaign of 2015 with strong concerns about the lack of funding for UK health services.

 However, the UK is not alone in this issue. A recently published international study of healthcare systems (of which I was a co-author) and which covered countries across both the developed and developing world, has suggested that most existing health systems are unlikely to remain sustainable in the absence of additional funding and/or the adoption of new, innovative approaches to delivering healthcare services. Only 9% of respondents indicated that the existing approach to financing health services in their country was sustainable in the long-term while 64% stated that it is unlikely or impossible to continue with the status quo.
Alongside health funding and configuration issues, it is clear that the demographic, technological and economic changes are creating additional demands on healthcare services at a time when the public are seeking further improvements in both the quality of services provided and scope of treatments available.

 The study, also uncovered significant challenges for policymakers, across the globe, tasked with pushing through major changes to respective healthcare services and systems in the face of a very resistant public, and during times of austerity and budget cutbacks. While there is no doubt major change is needed when it comes to the provision of healthcare worldwide, policymakers need to find a way to communicate this difficult message when the public often fiercely resists changes.

Overcoming such an array of challenges is a formidable task with no simple solutions. Two factors present themselves as the biggest barriers to those looking to implement change – one technical and one political. The technical factor concerns the organisation of the change process within healthcare systems with one of the biggest problems being that change has not always been done well and the public has a long memory when it comes to badly run projects undertaken within their beloved healthcare system. The lack of political consensus over healthcare reform is also a major barrier. There is a strongly held view that, because of the high priority given to healthcare policy by electorates, politicians use ‘health’ as a political football for scoring points against their political opponents, rather than focusing on what needs to be done. A key message for politicians is they must devise ways of communicating the essential need for major reformation of the way healthcare is provided across the world.

The early stages of the 2015 UK general election campaign suggests that politicians from all the main political parties are not prepared to heed these messages and try and communicate with the electorate about the need for reform of the current UK health system, for fear of losing votes. Instead they try and compete with one another about who can promise to  spend the most public money on the NHS – money which we don’t have and will have to be borrowed thus adding to national debt.

The full report can be found at: http://www.accaglobal.com/uk/en/technical-activities/technical-resources-search/2015/february/sustainable-healthcare-systems.html


Thursday, 11 December 2014

How do we hold governments to account 800 years after Magna Carta

Next year is the 800th anniversary of the signing of the Magna Carta which was a landmark in achieving accountability of government. The Magna Carta introduced the first standards of accountability in government by forcing King John to accept the basic principle that taxes should not be raised without first consulting his wealthy subjects. Also, representative councils had to be called to review the monarchy's expenditures.

As they say – the rest is history. In England, from this grew a form of constitutional monarchy in which parliament asserted increasingly greater powers. The development path was not particularly smooth because on the way we had the English civil war and the Glorious Revolution to name but two events

So where does this take us regarding the accountability of government. I would suggest we are now in an era which combines five major forces of change.

1.    Lack of trust - The first is the very low opinion and lack of trust in which Government and politicians are held by the electorate. Various parliamentary expense scandals, disgraced ministers hanging on to office and politicians generally ignoring the views of the electorate have had a corrosive effect. King John was a rotten king but recent behaviours by governments and politicians (while not as bad as John) have incensed many parts of the electorate. This is the case in the UK and many other countries and the impact must be that the public will no longer give politicians the benefit of the doubt which they might have done 30 years ago. The implications of this for accountability of government might be significant

2.    Constitutional changes - The second is the existence of potentially major “constitutional changes” in the UK following the Scottish referendum on independence. This is manifested in a number of areas including: further devolution to Scotland, Wales and NI, greater independence for city regions in England, more elected mayors for local government and the creation of an English Parliament etc. The implications of these changes for accountability of government need to be thought through.

3.    Political changes - The third is potentially major political changes in the UK and, to some degree, other countries. One aspect of this is the declining in support for traditional political parties and the significant growth in support for other political parties which tend to campaign on far narrower range of issues. Linked to this is the growth, across Europe, of political parties campaigning on an anti-EU and anti-immigration ticket. An implication of these changes is likely to be greater prevalence of coalition governments often in involving a number of small parties in government. Again the implications of this for accountability are potentially profound

4.    Austerity - The fourth is the continued pressure for more public services coupled with sluggish economic growth and financial austerity which seems likely to continue for the foreseeable future. Governments will no longer be able to throw money at problems as they have done in the past and they must now maximise the benefits from use of public funds available and demonstrate to the electorate that they are doing this

5.    The media - The fifth and final force concerns the role of the media. Following the phone hacking scandal and other unacceptable media practices, it seems likely that trust in the media has also declined and this may also have implications for the public perception of the media. The likely impact of the Leveson inquiry on the future behaviour of the media seem unclear. However, whether we like it or not, many many citizens will get information about Government activities through the newspapers, TV and radio rather than reading Hansard or Government and it remains to be seen whether the recent scandals will impact on this

Against all of this background we have to consider the way in which we make governments accountable (when they don’t really want to be too accountable) and how we improve the accountability process. I would suggest there are four aspects to this:

·         Scrutiny of policies and plans – the UK has quite a track record of public policy failure caused by failures of analysis. How do we open up the centre of government to public scrutiny about the way in which policy is formulated and the advice given by civil servants about policy options?

·         Responsibility and accountability structures– we now have elected mayors and police commissioners in some parts of public services to offer the potential for direct democratic control over services at a local level. To what extent does this need to be extended? How might this be extended to central government.

·         Reporting mechanisms – how should we provide better transparency about spending and performance in a manner which citizens can understand and without blinding them with too much detail?

·         Role of Audit – what should be the role of auditors in this environment? What should be the scope of their work? How independent should they be? Who should they report to?

All of the above are serious issues which can contribute to improved accountability of government

Tuesday, 25 November 2014

Welsh local government and voluntary mergers

At the time of writing, local authorities in Wales are considering whether to submit proposals to the Welsh Government for them to merge, on a voluntary basis, with a neighbouring local authority. Some Welsh local authorities have already rejected the idea of voluntary merger but a few seem likely to put forward merger proposals.

Such voluntary mergers have some advantages, over forced mergers, in that the two parties involved are committed to the merger and, presumably, have some affinity to each other. However, experience elsewhere (http://www.malcolmprowle.com/2012/11/mergers-of-public-sector-organisations.html) suggests that such mergers usually end up being the wrong merger. It is clearly important that there is a strategic rationale for any proposed merger and that the merger is seen as a means not an end.  However, this is not always the case and quite often mergers are undertaken for opportunistic or purely political reasons rather on merit. The possible voluntary mergers in Wales seem likely to fall into this category.

A related point is that proposals for reorganising local government arrangements in Wales usually involve some sort of process of joining together existing local government units. The problem is that the socio-economic geography of Wales has changed enormously over the last 40-50 years in terms of: population size and age structure, patterns of residence, employment locations and travel to work patterns, distribution of income and wealth, educational needs etc etc. Consequently, the existing local government units in Wales are probably, themselves outmoded and not fit for purpose in 21st century Wales. Just joining them together does not improve the situation

What is needed is a root and branch re-design of local government in Wales starting with the current situation and projecting ahead for the next 20-30 years. This would be very disruptive but, at least, we can expect a local government structure which will meet the needs of Wales for the foreseeable future.

To establish what such a revised structure might look like requires considerable thought and analysis. However, my initial ideas are as follows:

Greater Cardiff
Cardiff, Vale
West Glamorgan
Swansea, Neath/PT, Bridgend
North Wales
North Gwynedd, Conway, Anglesey, Denbigh
Newport, Torfaen, Monmouth, Blaenau Gwent
Caerphilly, RCT, Merthyr
West Wales
Carmarthen, Pembroke,
North East Wales
Wrexham, Flint
Mid Wales
Ceredigion, Powys, South Gwynedd
Greater Cardiff
West Glamorgan
North Wales
West Wales
North East Wales
Mid Wales


A number of points should be made about these proposals:
·         The above options have been developed on the basis of the following key parameters (in order):
o   Population size
o   Main travel routes
o   Equalisation of resource base
o   Natural communities
·         Some further adjustments might be desirable around existing boundaries with Powys and some population figures might change slightly
·         It is not necessary for all councils need to fall within a narrow population range but I think they should have a minimum population of around 200,000
·         Intuitively I suspect the Mid Wales authority would have to have very different organisational arrangements because of the large area, sparse population and lack of a major population centre
·         In doing this analysis, no consideration has been taken of any proposals to transfer responsibility for certain services (e.g., health, social care, education) from local government to Welsh government or vice versa.
·         Although these proposals are highly rational, it is probable that the proposals would completely unacceptable to all four main political parties.

Friday, 31 October 2014

Child abuse inquiry: Why we will never know the truth

If evidence was ever needed that the Government is not serious about investigating child-abuse in this country it is now clear for all to see. Concerns are continually expressed that this investigation: should be thorough, should “shine a light” in all sorts of dark places and should not be an establishment cover-up. Unfortunately it doesn't look like this is going to happen.

The first nominee for chair was an outstanding judicial figure with extensive relevant experience. Unfortunately, it turned out that she was compromised because of family relations and was intelligent enough to realise that her position was untenable so she dropped out of the reckoning.

The second nominee for chair, although having many strong qualities, is currently under huge pressure to stand down for a number of reasons:

·       She doesn’t seem to have much in the way of relevant experience – her experience seems to be in privatisation

·       She is clearly an establishment figure in all sorts of ways

·        She has personal links to some of the key people who are subject to investigation

This seems a damming list of negatives. You would think it in a country of some 60 million people, it would be easy to find someone who has relevant experience, is not an establishment figure and has no personal links. The sheer fact that the Home Secretary is desperate to support the current nominee suggests that such a person is NOT what they want to chair this committee. They are clearly scared about what might come out of the woodwork. Why else, did Leon Brittain not pursue the investigation all those years ago – he could probably and clearly see what and who was involved?

 I would suggest that whoever chairs this enquiry should have all of the following key attributes

·         They should NOT be a lawyer – legal advice can be provided to the chair and the committee as needed

·         They should NOT be living/working in London – this is too close to the establishment in this country and there are 53 million other people living outside London

·         They should NOT hold any form of honour (e.g. MBE, Peerage etc) and should indicate that they would not be prepared to accept any such honour in the future. The honours system in the UK is a malignant and malign system designed to turn people who are normally independent in nature into establishment cyphers

·         They must be intelligent and shrewd enough to be able to see through all of the obfuscation and dishonesty that will continually come their way

·         The investigating committee should have its own budget to enable it to acquire its own research and support staff. It is NOT acceptable for support to be provided by Home Office civil servants. The loyalties of those civil servant are to the Home Secretary who will be fully briefed about what is happening and will try to interfere. Forget “Chinese Walls” etc – they always fail.

·         They must have some experience of work in a relevant field (e.g. children’s services) although they don’t, necessarily, have to be an expert. The committee itself will be full of experts.

·         They should be able to demonstrate a background of independent thought and have a skin as thick as a rhinoceros. They are sure to face an immense amount of pressure and bullying from a variety of sources

·         They should have a good life insurance policy

Of course, there is not a “cat in hells” chance of this happening. There are reputations, fortunes and goodness knows what else at stake here and it is seen as far too dangerous to let the truth come out.

Friday, 24 October 2014

Where on earth are we going with public expenditure

In my inaugural professorial lecture at Nottingham Business School in 2009 I discussed the situation of UK public finances and the future of public services. (www.ntu.ac.uk/document_upload/92234.pdf)
One point I made was that the current situation was such that it should not be seen as a blip in the long term trend of increased expenditure on public services. Instead I suggested that it might be seen as a watershed in our social and economic history and something which should require a radical reconsideration about the way public services are organised and financed.

Since 2010, the present government has embarked on a “so-called” policy of austerity designed to eliminate the public sector deficit, reduce annual borrowing and stop the continually increasing mountain of public debt now around £1trillion. Originally the government aimed to eliminate the deficit and associated borrowing by the end of this parliament but this has not proved possible and, at the current time, it is unclear when the deficit might be eliminated. Thus the government is still borrowing billions of pounds each month which will have to be repaid ultimately by our children and grandchildren.

Until recently, at least the government could claim that its borrowing was being reduced even if not as quickly as would be desired. However, this week there came a sharp jolt. Government figures showed that government borrowing for September 2014 was £11.8 billion which was £1.6billion than for September 2013. This was much higher than expected and caused by a failure of limited economic growth to deliver higher tax receipts.

One particular point I mentioned, in my inaugural lecture, was that the constraints on future public spending were such that if the government wished to try and change people’s behaviours in some positive manner they would probably need to think more about sanctions for bad behaviour and less about financial incentives (which cost money) to encourage good behaviour. An example here might be actions to try and encourage people to adopt healthier lifestyles and subsequently reduce the burden on the NHS – this could be approached by using sanctions or incentives.

Imagine my surprise, therefore, to read that in the same week as the bad news about government borrowing was announced, the government has come up with two new and expensive schemes designed to try and change individual behaviour by the use of financial incentives. These were

·         Dementia – proposals were announced to pay general practitioners £55 for every dementia patient they identify. Leave aside the ethics and practicality of all this, it seem surprising that in these financially constrained times we are using public money to pay GPs to do what I thought they were already supposed to do under their existing contract
·         Obesity vouchers – suggestions, from government sources, have been made that the NHS might use its limited resources to offer financial incentives in the form of shopping vouchers to individual citizens in return for them losing weight.
These items come on top of a party political conference season where the main political parties competed with each other to see who could promise to spend the largest amount of public money (which we haven’t got and must borrow) on the NHS. 

It seems to me that the radical reconsideration of public services, which I referred to earlier, just hasn’t happened and the “chickens will shortly be coming home to roost”. Expect more large scale cuts in public spending after the general election irrespective of whoever wins. Also, the problems of the Eurozone and the World economy mean that another major economic crisis can’t be ruled out.