Saturday 11 June 2011

The hamster in the NHS waiting room

Some of my friends, with whom I have been debating the rationale for the coalition have referred to the NHS as the elephant in the room. I think it is that, but not in the sense they mean.

What they mean is, I think, this:

- both parties had policies for the NHS in their manifestos. The LibDem manifesto contained proposals for greater democratisation and accountability, and the Conservatives' for more efficiency, with a hint of privatisation. At the same time David Cameron was very clear in his promise that there would be no top down reorganisation. I read a blogpost which very helpfully set out the contents of the manifestos, but I can't find it now; I'll link later if I can find it.
- then Andrew Lansley came up with a radical set of “reforms” which suggested wholesale privatisation that went beyond either party's manifesto.
- the narrative is that the LibDems were bounced by this in a typical piece of right wing privatising Tory skullduggery. To an extent I think that is right, but he also bounced a lot in his own party. He bounced everybody in fact, not just the LibDems. The LibDem hierarchy was perhaps slow to respond in full measure, though in my view they've made up for lost ground since.
- although retrenchment is promised after the “listening” exercise, there is still a perception that further ambushes may be lurking round the corner.
- and there is a fear that the LibDems will get the kicking for this as we did on student fees, and will come out of it worse off.

But there is an entirely different set of issues which are really at stake, and nobody is actually talking about them. I want to deal with those and then deal with what I consider to be, in the scheme of things, a little local and temporary difficulty about this particular attempt at reorganising the NHS.

There are three key features to healthcare in this country at the moment. The first is that it is very expensive; the second is that the amount we are prepared to spend on it is limited; the third is that we are prepared to do very little about it. Neither of these is limited to the UK.

Western medicine is in the most expensive phase it has ever been in, and probably the most expensive it ever will be. We have much to be proud about. We are very good at major trauma and very good at keeping people alive. But our record on actually curing things is patchy to say the least. We cannot cure even things as simple as the common cold; what we do is deal with the symptoms until it goes away. We cannot cure AIDS, we cannot cure Parkinsons, we cannot cure Alzheimers, we cannot cure malaria, we cannot cure MS. I know, at bitter personal cost, that we don't have a clue about ME/CFS. We cannot even cure cancer – we can cure some cancers some of the time. The list goes on and on. What we do is keep people alive, often very expensively, often for decades, in greater or lesser degrees of comfort. Now, I expect and hope that as medical and biological knowledge advance, particularly at the quantum level, we will find ways of curing many of these conditions, or better ways of preventing them, and then we will all be leading better lives, and the average cost of care over each person's lifetime will go down. But for now we have to bear the cost. There's not much else we can do.

The second issue is what I regard as the actual elephant in the room – something nobody, least of all politicians, is allowed to talk about. We could undoubtedly keep more people alive, and keep them in less misery or greater comfort if we spent more money. I have no doubt that every hospital administrator in the country would efficiently and effectively spend an extra million doing good for a lot of people. But that million would come out of people's taxes, and the fact is that we – the public, you and I – are unwilling to see our taxes rise. So in the end it is you and I – not politicians – who decide who lives and who dies. But of course politicians are not allowed to say that; it would be taken as the worst faux pas imaginable if Andrew Lansley were to say “Actually people are living in misery, or dying, because you won't spend more money on their care”. But that is the truth of the matter. All the reorganisations in the world will not undo that truth.

There's another, although much smaller elephant, which is what we do about our own health. This is dealt with much more in public, although with not nearly enough effect yet. I speak as one of the villains here. I have just started taking blood pressure pills – yet to find the right combination or dosage. I am no doubt going to cost the NHS a fair bit over the rest of my life. This is largely due to the last ten years. I was fairly fit till around 2000, but since then I have sat too much, exercised too little, eaten and drunk too much and not the right kinds of food. My condition was avoidable, as are many of the conditions we are paying the NHS to treat. The difference that makes to the overall cost is staggering, but, despite great efforts by government and healthcare professionals, we are slow to get the message. In 2009 we topped a million alcohol related hospital admissions. That figure itself is staggering – I'll just say it again – over one million hospital admissions in 2009 were alcohol related. All but a few of those admissions were avoidable. I have not found any studies of what better personal health care might do for the NHS bill (if anyone has, let me know), but just let me put some very broad figures into the frame. The NHS costs approximately £2000 per person per year. (I'm using that as a very round figure for ease of use here.) That means that a village like this one, around 5000 people, is going to cost, or pay, whichever way you look at it, around a hundred million pounds over ten years. The effect of reorganisation on that (I'll talk more about reorganisation in a minute; this figure is for comparison) would be minimal, to be honest. If we were very lucky, we might save 10%, though I doubt if we'd ever see those savings materialise – see more below. But consider the possible differences if we lived “properly”. Our share of those million a year alcohol related hospital admissions would be avoided. My blood pressure pills – and those of most of the other other people in the village with blood pressure problems would be avoided – and I intend to live for a good thirty years more. I'm plucking a figure out of the air here, but I would not be surprised if the cost of treating us were halved by us living properly. Fifty million pounds over ten years, five million a year saved easily. And that's just one village. But we don't do it.

That sort of figure puts reorganisations into context. I think organisation is a very good thing. We need to make sure that the services we get are organised as effectively as possible, and, as conditions change, so the means of effectiveness change and reorganisation is a part of the process of ensuring that. But the NHS is over-reorganised. It has had major reorganisations in 1974, 1982, 1990, 1994, 1997, 2002 and 2007. Now they want to give it another one. Part of the rationale is that we won't be able to afford it without the intended reorganisation. I doubt that very much. I also think that the theme of not being able to afford it is, for some people, an excellent rationalisation for a doctrinaire determination to marketise the NHS. But I also think that politicians get sucked into using this language because they're not allowed to use it about the elephants in the room discussed above. If we don't change our lifestyles, and if we don't accept that we are actually ourselves daily making life and death decisions about the facilities available to other people, then indeed we will not be able to afford the healthcare we need. But they're not allowed to talk about our spending at all, and not allowed to talk about our lifestyle enough, so the theme gets exported onto the issue of efficiency. Now it may be that whatever set of reforms eventually goes through will make the NHS marginally more efficient. I doubt that, because reorganisation is itself a costly process, a very large sunk expense, and usually results in a great deal of changing the position of the furniture without actually effecting any radical change in effectiveness or efficiency. But we shall see.

I note that there were three reorganisations under Labour. I also note that Labour is being castigated for having thrown so much money at the NHS. Some of that money was wasted and some of it was used to boost salaries rather than add to service. But do please think back to the state of the NHS in 1997. We now have a guaranteed maximum waiting time of 18 weeks. That would have been inconceivable in 1997, and in my view the road from there to here was paved partly with reorganisation but largely with money.

Bringing some kind of market disciplines to bear is one thing. There is a trick to doing that without making the NHS market led, a very difficult trick, but nonetheless an achievable one, I think. Ruling the NHS by market forces is a very different thing, and in my view is pernicious. I call the USA as my witness – a market led system, in which they spend nearly twice as much of GDP as we do, for outcomes that are only marginally different. The NHS is founded on the idea of equality and markets thrive only where there is inequality; to subject the NHS to market forces would be to build in inequality. Some will say we already have inequality; it is just masked by the current system. That is indeed true, but I suspect that inequality rises as market penetration into the system increases.

Anyway this reorganisation will make some sort of difference, I am sure, but not much. It is much more important to politicians than it is to the NHS. It will be a big political football over the coming months and years. It will make the careers of some politicians, maybe, and it will ruin the careers of others, most likely. It will be a massive political issue, but its effect on the outcomes of healthcare in this country will be minimal. That is why I regard this, big though it is for Tories, LibDems and Labour, as a little local and temporary difficulty in the NHS. It is a hamster in the waiting room by comparison with the two elephants discussed above. At last we've arrived at the title of this piece. Compared to our willingness to pay and our willingness to look after ourselves, it really is hamster sized. And that is why I am content to talk about it as a strategic and tactical issue for the LibDems, rather than something of genuine importance to the nation.

As for the strategy, I think it is quite simple. It's much easier for us than tuition fees. It is evident that this is a Tory thing, not a LibDem thing. We will be excoriated by some just for being in the coalition that is proposing this (they always will, regardless of how illogical it is), but for most people in the country, it is identifiable as a Tory issue. It is noticeable that the overall perception of the Tories as not safe for the NHS is still strong, despite David Cameron's best attempts to decontaminate. PoliticsHome's poll on this issue makes interesting if complex reading. Their conclusion is that the public still don't trust the Tories, despite apparently liking some of the ideas. They conclude that there is still more danger in it for Clegg than for Cameron; there is some truth in that. It may be perverse, but that's the way voters are, and it illustrates the need for LibDem strategy to illustrate that our power is limited, but that this is not in itself a condemnation of coalition, that we are different from the Tories in terms of our strategy for the NHS, that we have been instrumental in mitigating the Tories' worst ideas,and, above all, that coalition actually works. Tactically this calls for subtlety in handling, demonstrating the difference and the benefits of having LibDems in government, while not making relations so difficult as to prevent us doing the job we're there to do. Our leadership is capable of that.

The tools we use to implement those tactics are up for grabs, but just as a last note, it might enable us to resurrect Mark Pack's lost idea “community politics”. While I can appreciate our government's wish to foreground the big society idea, I think we can do ourselves some good by keeping the theme going, indeed emphasising it, that there are differences – notably that we've been on the ground of community politics for a long time, unlike Dave's relationship with his new Big Society idea. And we can also emphasise that what we want for the NHS is absolutely in keeping with the principles of community politics – giving genuine power to the people rather than trying to hand over responsibility without power.

Thursday 9 June 2011

Short reasons to be cheerful

One of my readers said he read my post “Reasons to be cheerful” right through to the end, but “the reality of modern politics is that very few will get to the end, so having summed up your thoughts very nicely, how about summing them up in a pithy slogan? “ I wasn't sure about that, to be honest. I don't know about blog reading habits in general, but certainly, in terms of my own habits, I read my way through some hefty posts if they grab my attention. And I have many of the characteristics of the butterfly when it comes to concentrating. But I took his remark as a challenge. So here is a short version.

I haven't thought of a pithy slogan yet: "LibDems in grown up government action shocker" is the best I've come up with.*

I've also thought of "Still LibDem, still working for all the people, still sensible, now with long term vision".

But here is a summary:

- going into the coalition was a viable action politically
- going into the coalition was also morally right; the country needed stable government and no other option offered the possibility of such stable government
that disconcerted a certain proportion of LibDem voters, many of whom were actually “none of the others” voters
- but it left us with the opportunity to appeal long term to sensible, liberal minded voters
- the party leadership's strategy is a sensible long term plan to demonstrate that we can govern and that coalition works
- we are getting some new experiences – being kicked because we are in government is one of them
- we still get some familiar experiences – the media still heap s*** on us; they always did
- the left and the right, particularly the hard right, will continue to heap bile upon us; they always did
- we have a joint programme with the Conservatives to rescue the economy which will take time to work
- but we are different from the Tories and we claim success in moderating some of their destructive tendencies
- we will eventually get the credit for all of that
so, although now is squeaky bum time, we have to hold our nerve, and...
- to keep working, because where we work we win

Those who have short attention spans can stop here.

A couple of additional points. I know we've been stuffed by a couple of setbacks that may or may not have been our fault – student fees and the NHS cock up. We make mistakes. All parties do. Maybe student fees was one. I say “maybe” - it is becoming received wisdom that it was a big mistake for our MPs to sign that pledge. I'm not so sure – it is difficult to see what else we could have done, given our official policy. If all our MPs had refused to sign, great play would have been made of that by Labour and Tories, and we might have been distracted from the main task. I also think we didn't manage the fall out as well as we could. It's been stencilled into the public perception as a broken promise. It was not. You break a promise if you are in a position to keep it and decide not to. We were not in that position – never were. We might have worked more effectively to mould that perception.

Some things will go against us – the point I made in my first post, that we have one sixth of the seats the Conservatives have is a very important one. They bounced us, as well as the rest of the country, with their ill thought out and doctrinaire plans for the NHS, which were not in their manifesto, and in fact run contrary to David Cameron's pledge that there would be no further top down reorganisations of the NHS. Maybe we need to be more tactically astute over the NHS than we were over student fees, and make sure that if anybody gets blamed it is the Tories, whose idea it is, and not us.

*Daily Mail version "LibDems governing sensibly shock; cause cancer".

Monday 6 June 2011

Reasons to be cheerful

I've had a couple of conversations with local LibDem colleagues lately who have been looking rather down in the mouth – poor results on May 5th (despite good results here), doubts about the coalition, doubts about the future. I found myself saying to them that I feel strangely cheerful, and then had to enumerate the reasons why. They are a combination of ethical and political issues.

The first reason is the fact that we're in the coalition in the first place. I think more and more firmly that the party leadership made the right decision – not just the right decision for the party but for the country. The country needed (and still needs) a stable government to get us through this economic crisis. That government is being provided by the LibDems in concert with the Conservatives. It felt unlikely when it was first mooted, but it has happened as it has by and large governed well. The fact that we are able to argue about things like voting reform and the precise nature of changes in the NHS shows that we have done the hard things reasonably well. We need to think in terms of long cycles as well as short ones. Nick Clegg's strategy was to position us to take the credit as much as the conservatives if we are in a good position in a few years time. We are still on course to do exactly that. It's a different experience being in government. When you're in government, people kick you because you're in government. That's a different experience from being kicked because we're Libdems, which we're used to, and it works on a different logic. People often register short term resentment at polls between elections, but give the party credit, albeit grudgingly, at election time. If we hold our nerve, that prize still awaits us. I was very pleased to see Tim Farron say much the same soon after the elections: "Enough doom and gloom, we have the greatest opportunity in the history of our party".

We were even more under pressure a couple of weeks ago with the sharks doing their best to circulate around Chris Huhne. But a week is a long time in politics, and a fortnight even longer. Chris may not be quite out of the woods yet, but he is last fortnight's news – last week's news was Andrew Lansley. And we've even moved on from him – modern politics moves fast.

The sniping will go on. We are viable targets for the media – not just LibDems, but Libdems IN GOVERNMENT, shock horror. Those who loved to hate us still do. The level of bile against us on ConservativeHome remains just the same. Go there and see the comments on... well, on pretty much any post. That's politics. They were spitting just as much bile at us before last year's election and it didn't stop us getting our message across – it won't next time either. And we will get it from the media as well. Last week's Observer's cheaply hostile editorial about the NHS rehashed the old meme “It's all Nick Clegg's fault”. It was mostly about Cameron and the NHS, and it followed a standard, for all papers, editorial line, of declaring that Mr Cameron now has a dilemma between softening the bill and displeasing his right wing or driving it through and thereby displeasing everybody else, thereby attempting to sound weighty and statesmanlike without having to come up with a solution. The LibDems are reduced to an opportunistic bit part, changing our tack because we are concerned all of a sudden for our survival. What do you expect after the setback we've just had? Sail on merrily towards the iceberg? “To change course would be unprincipled”? No, we steer round the iceberg and them resume our intended course when we are able to.

But what I like most of all is that, despite all the pettiness and meanness directed at us, we are showing how grown up politicians can be. And not just politicians in general, but Liberal Democrat politicians. The old excuse that a vote for the LibDems is a wasted vote because they'll never get in to power is shown up for what it is – nonsensical. Being grown up has its downsides of course, not least missing the Short money that gave us a budget with which to oppose. It is perverse that there is no similar budget to allow us to govern, but that is the case, and we must make do – and by and large we are making do. There was another report this week which examined the role the LibDems are playing in government, and was spun by the media to say we're not doing it well. The idea of putting a minister in every department spreads us thin. If we'd chosen a smaller number of ministries to go into we could have concentrated our power and had more of an effect in those departments. No shit, Sherlock? What annoys me most about post-coalition debate is the assumption that, because we haven't got everything we wanted, we have therefore failed. It's a peculiarly British assumption to do with the nature of power. We tend to think that power is a zero sum game and people either have it or don't have it. The concept of shared power seems to be alien to British thinking. Maybe that's why the idea of coalition is so difficult for some people to accept. The assumption behind much media reporting is that because we don't get everything we want, we must have failed. No, we haven't failed. We have one-sixth the number of seats the conservatives have.* On that basis we should get one-sixth of the results, and on the whole we've done better than that. The Guardian's headline, by the way, reads: "Deputy PM's office ineffective, report on coalition government finds. Document says most decisions reached through informal channels rather than formal coalition machinery". In the Guardian's view it's clearly a bad thing, if you read the rest of the article. But I find myself wondering in what way that constitutes a bad thing. I know it's a problem to journalists who can only think in binaries, but governments work on the basis of informal relations as well as formal relations. Nick and Dave get on well, so they're using that. Why should they not? In what way is that somehow unconstitutional or ineffective?

We continue to have to put up with misreporting by media who are perhaps not biassed against us, but just need conflict for a good headline. Vince Cable comes in for more than most. He was headlined as "Cable attacks 'ruthless' Tories" when he called them "ruthless, calculating and thoroughly tribal". In the interview, which you can listen to on that last link, he said it in a perfectly affable tone of voice, and he went on to say, immediately, in the same sentence, "but that doesn't mean we can't work with them". They're at it again today: "Vince Cable warns GMB against co-ordinated strikes". He is getting a simplistic knee jerk reaction from the GMB, who clearly don't understand coalition politics either.Fortunately, cooler heads area round to give a truer picture. Paul Waugh on PoliticsHome, Why Cable's no Tebbit, points out that Cable is giving the unions the political reality. Cable has no wish to crack down on unions, but there is a very strong body of opinion within the Conservative party that does. A wave of strikes would give them motive and opportunity. Cable counsels wisdom, not quiescence. The media are not helpful to us, but then they never were. We just have to continue to work.

The left wing don't like us, because we're not left wing. Those who used us as a convenient protest vote don't like us because we've grown up. The right wing loathe us because, well, because we're human. We are definitely doing something right. But we need to connect that again to what voters want. Politics is a tough business and it will go on being tough. The rules have changed because we are now in government, but the nature of the game hasn't. It's still true that where we work we win. Besides working we need to hold our nerve, something we have not had to practise so much in the past, and we need a narrative, aversion of events that holds true for us and that we can sell on the doorstep. that narrative is taking some time to emerge, but the bones are there in place:
- coalition does work (and we are proving that)
- we do do a lot of good for the less well off (which again we can prove)
- we have moderated a lot of Conservative policies into sensible ways forward (and we have blunted the glaringly socially authoritarian wing of the Conservative party (something I am delighted about, and so should everybody be who is not a glaringly socially authoritarian Tory. For a glimpse of why see here. I suspect, by the way, that Dave is monumentally pleased that he has the LibDems to lean on and not his own right wing.)

So, to sum up:
- we are still Liberals. That's absolutely clear from the policies we are putting in place and the policies we have prevented from being enacted.
- the media are not helpful to us, but they are no less helpful than they have ever been.
- we need to find, and will find, a new constituency of voters. Those who voted "none of the others" don't have that easy option any more, but there are plenty who will vote for a liberal and capable government in the UK.
- and this time we have a time scale, a long one. It won't matter if we're still unpopular in a year's time, as long as we are building, in policy achievement and in campaigning, towards a sustainable recovery for the country by 2015, because I am as near certain as I can be that that will mean a sustainable recovery for the LibDems. It will be hard work. It always was hard work being a LibDem. But we mustn't lose our nerve.

*Despite having two thirds of their votes. (FPTP is *such* a fair system.)**

**For those unable to detect irony, that was ironic.

Do right wing Christians actually need to lie?

A question I've been pondering for a day or two. I heard Nadine Dorries on Any Questions. She's really bad for my blood pressure. Among other gems was the statement that skunk cannabis as sold on the streets today is 50 times more powerful than traditional cannabis. I know of no scientific basis for that statement. I'm not an expert - there might be one, but I doubt very much if I'll ever get the reference from Nadine. If anybody does have a reference to a scientifically valid demonstration, please let me know. That of itself is just a minor issue, a fantasist trying to portray the world how she wants it to be rather than how it is. But what struck me most about it is the ease and facility with which she lies. I've no idea whether she actually believes what she's saying, but she admits to lying quite readily - her blog, she said, is 70% fiction, designed to paint a picture for her constituents, presumably with the aim of getting them to vote for her again. But why, as a Christian, does she feel that that is appropriate behaviour? A trawl through the pages of the bible would rapidly suggest that lying is not seen as a Christian activity.

And then today I was reminded by a tweet from Andrew Page of the existence of Conservapedia. It was about their page on atheism. I'm not going to link to it, because it's down there with the Daily Mail in terms of gutter, vitriol, and sheer blatant untruth. It would be hilarious if they didn't mean it. If you want to, google it and go and read. Marvel at the section on the three way link between atheism, lesbianism and obesity. I am staggered again at the volume of complete falsehood. And presumably they know what they are doing. So what is it about these Christians that lubricates such consistent telling of untruths.

Please note I'm not being "anti-Christian" here. I am a Christian. I'm trying to figure out how someone who in name shares the same principles that I do can feel that such wholesale lying is justified.