Another Christmas of crisis for the NHS

‘Tis the season for NHS tales of woe, featuring ‘bed blockers’, diverted ambulances and long waits on trolleys in hospital corridors. That the NHS is in crisis again as winter takes hold is as inevitable as Christmas itself.

This time around the cause of the Christmas non-cheer around the NHS was triggered by the stepping down of Lord Kerslake, from his chairmanship of King’s College Hospital Trust, following a decision by NHS Improvement to put the trust into financial special measures. While the government cynically sought to blame the trust’s problems on Kerslake and his team, he argued in the Guardian that ‘fundamentally, our problems lie in the way the NHS is funded and organised’. Massive overspends, recruitment crises and crippling pressures on services are indeed commonplace across the NHS.

‘The government and its regulator’, he says, ‘are simply not facing up to the enormous challenges that the NHS is currently facing’. And this isn’t just about funding. Despite an extra £2.8 billion promised in the Budget for struggling health trusts (short of the £4 billion a year demanded by NHS chief executive, Simon Stevens), and the £350million announced in the Budget to address winter pressures (coincidentally the same amount that was plastered on the side of that Brexit bus), the problems in the NHS persist. They will not be fixed, it seems, by simply throwing more money at them.

From primary care to home care, young people’s mental health to dementia care, the system is in meltdown. The number of patients waiting in A&E for more than four hours has more than doubled in as many years. The number of ‘long-stay patients’ in hospitals has also increased, largely as a result of an absence of care provision in the community for those who are fit enough to go home. And with bed occupancy levels now approaching 95 per cent, the likelihood of yet another Christmas log-jam in NHS hospitals is increasing.

Crisis preventative measures, such as encouraging people to have the flu jab and to consult their pharmacist rather than their GP if they have a minor ailment, are reportedly having an impact. And yet the overall demand on services is still intensifying as the resources at the NHS’s disposal become more scarce. You know things are bad when an article in the British Medical Journal could — only half tongue-in-cheek — blame the ‘highly dedicated and responsive GP, Dr Brown Bear’ in the kids’ cartoon Peppa Pig for ‘fostering unrealistic expectations about family doctors’.

We need to go beyond the usual to-and-fro of NHS cheerleading on the one hand, about how much Brits ‘heart’ it, and NHS doom-mongering on the other hand, where the spectre of its imminent privatisation is constantly being raised. People like Stephen Hawking aren’t helping when they lend their name to a legal dispute against the establishment of accountable care organisations (ACOs), which they say herald the beginning of the end for ‘our NHS’, when in truth they are just institutional arrangements designed to integrate ‘silo’ services across the health and care system.

But Hawking is right that we need ‘proper public and parliamentary scrutiny, consultations and debate’ in relation to the NHS. As is Kerslake when he says: ‘We desperately need a fundamental rethink. Until then we are simply kicking the can down the road.’ Instead of obsessing over paper targets, or targeting peoples’ lifestyles and behaviour through the health system, the political class needs to engage the nation in a debate about the future of the NHS. Whether that ends in radical reform or starting all over again is open to question — but we know for sure we cannot continue with the crisis-ridden and cash-strapped status quo.

First published in sp!ked

The Lonely State

Over the summer, we were treated to ‘the biggest neighbourhood celebrations since the Jubilee street parties’. The organisers eagerly ‘inviting people to get together with their neighbours’ and attend a ‘street party or a shared barbecue, a picnic or a bake off’. But this time around we were urged, all too pointedly, to ‘celebrate all that we hold in common’. ‘Inspired’ by the murder of MP Jo Cox, the feel-good factor was notable by its absence; and in its place were some darker assumptions about the divided, nastier society the organisers imagined we have become.

One of the four areas of work undertaken by the recently established Jo Cox Foundation is to address what it describes as the ‘growing crisis of loneliness’. ‘It can affect people of all ages and from all backgrounds – from the bullied school child, to the new mother, to the pensioner who has outlived her friends and immediate family’, we are informed. The Foundation wants to ‘try to get people talking at all levels’ whether it’s ‘chatting to a neighbour, visiting an old friend, or just making time for the people they meet’. And, ironically enough, the Foundation is not on its own with this initiative. Loneliness is all the rage.

Until quite recently, unfashionable charities organised befriending initiatives for older people left behind by family or deceased partners, or house-bound by disability. But today the category of ‘the lonely’ has widened. Whether it’s social media isolating rather than connecting the young, and intensifying a (quite literal) status-envy; or the plight of relatively young singletons living on their own out of choice or lone-parents with only screaming children for company; or even those leaving behind those elderly relatives to immerse themselves in study or work, and consequently experiencing loneliness themselves.

Julianne Holt-Lunstad, professor of psychology at Brigham Young University, has generated a number of alarm-filled headlines recently. She was presenting to the Annual Convention of the American Psychological Association, what one commentator described as the ‘biggest ever review into the problem’. She described not only an increase in loneliness in the U.S., but also concluded from a number of large scale international studies, that social isolation, loneliness and living alone are leading to premature death around the world. Its impact is worse than obesity, she said. Not only does Holt-Lunstad say we have a big disease-like problem. She also claims that if only certain interventions were made, ‘social connectedness’ could flourish and lives could be saved: whether by training kids in social skills at school or getting GPs to screen their patients for signs of loneliness.

It is this diseasing of loneliness – both in the way it is described and the impact on people’s health it supposedly has; and the exaggeration of its extent that is most striking today. It triggers a stress hormone, increasing blood-clotting ‘in anticipation of injury’ raising blood-pressure and clogging up arteries, says one researcher. It can ‘dampen a person’s immune system’, says another. It causes depression, says one campaigner; and cancer, insists another. So, as if being lonely isn’t bad enough, it also has (if we are to believe what we are told) quite literally deadly implications.

According to a Leader in New Scientist, ‘Curing loneliness might just be the most cost effective public health intervention available’. In truth, we can’t ‘cure loneliness’ anymore than we can cure sadness (whatever the pretences of advocates of the happiness agenda). And we shouldn’t try to either. Indeed there is much to recommend the explanation which says social isolation can mean people’s deterioration in health goes unnoticed. It is also the case, despite what campaigners say, that the old and already unwell are still the most likely to experience loneliness. Still, there are a lot of lonely people out there. The question, as Paul McCartney sang, is: ‘Where do they all come from?’

It is not altogether a surprise to discover that loneliness is a big problem today. The progressive decline of social institutions over a period of decades is well known: from the family to the pub, the trade union to the working men’s club. In the absence of those institutions, the individual increasingly stands alone, turned in on themselves, albeit deemed vulnerable and ‘at risk’ and looking to the state or experts for ‘support’ and protection. But there is nothing inevitable about the way being with others has been turned into an ordeal of etiquettes and hazards as is increasingly the case: from gaining consent on campus and avoiding commitment in relationships to anxiously keeping the kids away from strangers.

Feeling lonely is normal. It is not a disease. You can’t teach children how not to be lonely. It is a feature of our interior lives, it is intangible and subjective. And it is not particularly receptive to policy interventions however well meaning. But, while we can’t solve the problem of loneliness as such, we can do something to make our communities feel less isolating and less conducive to feelings of loneliness. The state can play a positive role in sometimes quite literally bringing people closer together – improving transport and communications and making it more affordable for people to get around. But the obsession with congestion charges and cycle paths over building more roads and airports, and with the supposed dangers of surfing the internet over improving dodgy wifi connections; shows how little interest policy-makers have in genuinely bringing people closer together on a scale that would make any real difference.

But it would be better, in other areas, if the state could do a lot less. It could stop the unnecessary checks on volunteers and care workers that can put people off helping others and stoke anxieties about abuse. It could revoke the illiberal powers it has granted local busybodies that so contribute to the inhibiting of public life – from confiscating alcohol to banning skateboarding, from banishing buskers to demonising smokers. For here too, far from fostering a social environment that frees us up and connects us with each other, the political class’s enthusiasm for regulating people’s everyday lives and relationships only helps isolate and alienate us further.

The obsession with loneliness has not just sprung from nowhere. There has been a therapeutic turn in policy-making and in society more broadly; and, post-Brexit, a uncomprehending elite reaction to a society they imagine to be somehow less friendly than it was a year or so ago. Instead of delivering concrete policy interventions to solve discrete social problems we have initiatives that will supposedly make people feel better about themselves, improve their ‘wellbeing’ and encourage some fellow-feeling. The political class projecting their own alienation and dark thoughts about what we’re like onto us, and already consumed by anxieties about their own isolation and disconnectedness, have little interest in building infrastructure or in letting go their grip on people’s everyday lives. The truth is they just can’t leave us alone.

First Published in Huffington Post

Tube Strikes and Dairy Deals – Solidarity or Subsidy?

So RMT (Rail, Maritime and Transport Union) and TSSA (Transport Salaried Staffs’ Association) have announced another two days of tube strikes to take place later this month. This is following on from last month’s day-long disruption and other recent actions to do with the introduction of the ‘night tube’ and a threat to station jobs.

We should say thank you. Thank you to the drivers, station staff and the rest of them, for standing up for themselves.

Too often today we’re told, as Margaret Thatcher used to put it, ‘There is No Alternative’ (TINA). These two transport unions sees things differently. But compare this with the deal, announced on the same day as the tube workers’ strike action, between the NFU (National Farmers’ Union) and Morrisons. The supermarket chain has agreed to top-up the price of milk to stop farmers going out of business. A new brand called Milk for Farmers will mean that for every litre sold in the latter’s stores farmers will receive 10p.

Why should consumers subsidise dairy farmers? We might be sympathetic to their situation, but we don’t owe them a living and the industry can’t survive indefinitely on charity. There’s a difference between workers acting collectively to demand a better deal or to protect themselves, as RMT and TSSA are doing; and an already state-subsidised industry seeking further subsidies from consumers, as the farmers’ union is doing.

There’s also a difference between withdrawing your labour and walking-out of your job and walking a couple of cows through the aisles of Asda in the hope of gaining some media-fuelled attention. But even real workers – are farmers really workers in a selling-their-labour kind of way? – seem more interested in gaining our sympathy than taking on their employers. For instance, care workers, particulary home care workers who look after the most basic of everyday care needs for elderly and disabled people in their own homes, are famously put-upon.

This is typical from a care worker in a letter to the Guardian:

Yesterday, I started work at 7.30am and finished at 5pm, then I worked a 10pm to 7am night shift. I washed and dressed people, cleaned up their urine, their faeces and their homes … [O]ne day someone will tell me they pay their cleaner £12 an hour and it will be the final straw.

We are rarely asked to express our solidarity with our fellow workers these days – otherwise there’d be a lot more support for the two days of strike action. Instead we are expected to emote and show how badly we feel for the poor and downtrodden. But this cannot be relied upon. Should the public really feel sorry for farmers over-milking their plight as much as their cows, or for contracted-out care workers who demand our pity but are, rightly or wrongly, held responsible for poor and neglectful care amongst their number?

That’s why I’m on the side of the relatively well paid and assertive tube workers. They have earned my respect (without courting it) and inspire a confidence in the capacity of ordinary people to shape their working lives. The travelling public should not grumble about the temporary inconvenience of longer journeys to and from work. Shake them by the hand. By defending their own interests and striving for more for themselves, they are standing up for us all. Good on ’em I say!

First published in Huffington Post

Nothing great about the welfare state

In The Welfare of Nations, the decade-later follow-up to his The Welfare State We’re In, James Bartholomew – former leader writer for the Daily Telegraph and the Daily Mail – takes us on a tour of the world’s welfare states.

It’s fair to say he isn’t a fan. He argues that the welfare state undermines old values and ‘crowds out’ both our inner resourcefulness and our sense of duty to one another – including our own families. Instead of aspiring to be self-reliant, the welfare state makes us self-absorbed. People aren’t encouraged to exercise responsibility anymore; instead, they are handed a plethora of ‘rights’. Welfare states ‘have diminished our civilisation’, Bartholomew concludes.

The welfare state has always been a problematic entity, from its modern beginnings in the nineteenth century with Bismarck’s cynical ‘state socialism’– built as much to placate the increasingly politically active masses as to attend to their welfare – to the vast systems maintaining millions of economically inactive citizens across the world today. The welfare state, as its advocates contend, always promises a better society, with higher levels of equality, but, as Bartholomew counters, it also tends to foster unemployment, ‘broken families’ and social isolation.

Some versions of the welfare state are better than others. Wealthy Switzerland has a low unemployment rate despite generous social insurance-based benefits. But, at the same time, the Swiss state imposes tough conditions: there’s no minimum wage and workers can be fired on the spot. Sweden’s benefit system is generous, too, but if you can’t afford the rent on a property, you have to move out.

In the UK, matters are equally complex. For instance, shared-ownership schemes, ‘affordable housing’ and planning regulations contribute to distinctly unaffordable house prices. Indeed, housing costs have risen from 10 per cent of average UK household income in 1947 to over 25 per cent. For the poorest sections of society, it is worse still. This is despite the fact that the state subsidises dysfunctional, workless households on bleak public housing estates.

And what of state education? Nearly one-in-five children in OECD countries is functionally illiterate. The best performing advanced countries have autonomous schools, ‘high stakes’ exams, quality teachers and a culture of discipline and hard work. Compare that to the US, where you can’t get rid of bad unionised teachers in the state schools.

Bartholomew convincingly argues that state schools’ ‘shameful’ inadequacy, for all the rhetoric to the contrary, breeds inequality. He fears that the success of the free- and charter-school movement is at risk, too, from ‘creeping government control’. Bartholomew is upfront about his own old-fashioned conservative views. He’s a kind of evidence-based Peter Hitchens, using ‘bundles of academic studies’ to show what he suspected of the welfare state all along. The care of ‘strangers’, he argues, is bad for children and aged parents alike, and damages the social fabric. Over half of Swedish children are born to unmarried mothers, whereas the family in Italy, he says approvingly, is ‘the main source of welfare’, with charity-run ‘family houses’ (no flats or benefits) for single mothers. At a time when Conservatives aren’t really very conservative, it takes Bartholomew to ask important questions about social change.

Again, southern Europe offers a useful contrast to the situation in northern Europe. Over half of single people aged 65 or over in Italy, Portugal and Spain live with their children. Just three per cent of single Danes do. Should individual autonomy trump the burden of caring for children and family members? What role should the state play? UK social workers are office-based, writes Bartholomew, and contracted care workers follow ‘rules rather than doing things from an impulse of loving care’.

By 2050 over a third of the European population will be aged over 60. Even though the age at which people are eligible for pensions is increasing, state pensions can’t be sustained, says Bartholomew. In Poland, Greece and Italy, pensions account for more than a quarter of public spending. The UK spends nine per cent of its national income on healthcare, the US an insurance-fuelled 18 per cent, and Singapore just five per cent (though Singapore has to put twice that into ‘personal’ health-savings accounts). ‘Wealth leads to better healthcare’, says Bartholomew, but the monopolistic UK system, despite the NHS’s officially cherished status, is one of the worst of the advanced countries for health outcomes, including, for example, cancer-survival rates. ‘Obamacare’ notwithstanding, millions of uninsured Americans – neither poor enough for Medicaid nor old enough for Medicare – struggle to pay for healthcare.

Democracies, says Bartholomew, are susceptible to the fantasy that welfare states can solve our problems without consequence or cost. This is despite US public spending increasing from seven per cent of GDP in 1900 to 41 per cent of GDP in 2011. In 2012, France revealed that public spending accounted for 57 per cent of its GDP.

But it’s Bartholomew’s critique of the wider welfare culture, rather than his carps at benefits systems, which provides an important corrective to what can be a narrow and mean-spirited discussion. He also offers practical solutions: let’s increase housing supply but abolish public housing; let’s have a system of ‘co-payment’ for healthcare between state and individual; let’s allow schools and hospitals to compete in markets; and let’s give individuals the opportunity to save and insure themselves to pay for social-care needs and pensions (albeit through Singapore-style compulsory bank accounts).

So what do we do with the welfare state? As Bartholomew puts it, the welfare state, rather than capitalism or communism, was ‘the ultimate victor of the turmoil of the twentieth century’. But Bartholomew makes clear that this is a hollow victory with many millions left idle and communities undermined. So yes, let’s cut the welfare state down to size and stop infantilising its dependants. But we also need to get more ambitious than Bartholomew allows. He thinks it’s too late to get our freedoms back and argues for a minimal ‘welfare’ state only. But why stop there? If the architects of the welfare state have anything to teach us, it is to be bolder in our visions.

First published in sp!ked

Care in the community is vital to help pensioners and disabled people

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THE Care Bill is a bid to tackle the agreeable problem that we live in a society where more people are living for longer.

It sets a cap on what people will have to pay for their care and a minimum threshold of need at which people will be eligible for social care.

But the critics are not hopeful. There is the demographic challenge, the slashing of budgets and concern that the reforms will bankrupt local authorities without necessarily making care any more affordable.

This is where community comes in. The idea is that communities have an important role to play in supporting old people. As former Care and Support Minister Paul Burstow says, “without community, independence can become miserable isolation”.

While we might expect care workers to have regard to the person they are caring for, they can’t take the place of neighbours, family and friends.

Norman Lamb, the current Care and Support Minister, has therefore proposed the setting up of Neighbourhood Watch-style schemes. But can we really expect people to act in a neighbourly way? Negligent, if not downright abusive, neighbours are apparently responsible for the loneliness and isolation experienced by many pensioners.

Health Secretary Jeremy Hunt has referred to this as our “national shame”.

He argues that, instead of putting our elderly relatives in care homes, we should adopt the “reverence and respect” towards the elderly typical of Asian societies and, presumably, accommodate them ourselves.

But can we put our trust in our families and communities when local authorities too, in an effort to appear pro-actively protecting ‘vulnerable’ older folk, would rather give the impression that we are routinely abusing them in their own homes?

Despite these mixed messages, most of us understand that our communities are, on the whole, safe and caring places. But community is all about relationships and these are made possible by a good degree of mutual trust.

This trust is being eroded by the obsession with alleged abuse and neglect on the part of the authorities.

Confirming people’s worst fears is hardly conducive to building a sense of community. Indeed, the interventions of supposed protectors of the vulnerable represent the biggest threat to community, by actively undermining the relationships that underpin it.

Communities really can, and often do, play a safeguarding role towards those who, as a consequence of old age, ill health or disability, may need support.

While an unburdening of the state and a reburdening of communities is no answer to the elderly care problem, there is much to recommend the idea that neighbours, by looking out for each other, can safeguard vulnerable people.

First published in Derby Telegraph