Reforming the NHS and the laws of politics

Many years ago as a young local councillor, I discovered that politics is bedevilled by the sheer irrationality of our electors.  London Transport (as it then was) proposed to make some perfectly sensible changes to the bus network in my area, and held a public consultation.  A woman rose and made an impassioned speech in two parts: 

(A)  the current bus service was shit;  and 

(B)  it mustn't on any account be changed, in any particular.

I was very glad it wasn't me in the chair, because I find it really difficult dealing with stuff like that ( - the same motive that caused me to recoil from being foreman of the jury on which I sat recently; and was heartily grateful someone else accepted that solemn duty).

The public's attitude to the NHS is the same, only on a truly monstrous scale.  Here's an extract from a piece in LabourList last week: 

Normal people are very capable of holding contradictory views in their heads, especially in subjects about which they know little but feel strongly ... paradoxes, which have regularly been witnessed in opinion research ... are of profound importance as Labour thinks about how to frame its NHS offer running into the next election. They are:

- Everyone loves the NHS and yet in focus groups it quickly becomes apparent that absolutely everybody has a personal horror story about waiting lists or botched admin. These stories flow from them like a public policy fever dream.

- Everybody knows that the NHS is in desperate need of reform – and yet in focus groups almost nobody believes such reform will work. Getting people to imagine a high-performing NHS is very, very hard.

- Everybody knows that the NHS is in desperate need of investment – they see it with their own eyes every time they visit a hospital. And yet nobody believes it will make any difference to the service they are experiencing.

The piece goes onto say that "[Wes] Streeting’s speech at [Labour party] conference seemed to try to reflect these paradoxes and even solve some of them."  He's also recently told the Royal College of GPs that Labour "won’t entertain requests for blank cheques", which is rather what they have in mind.

Assuming he & the rest of Labour are seriously preparing for power (as well they might), I very much hope this all means they have taken heed of Drew's Laws of Politics #1:  Never buy off anyone at a higher price than absolutely necessary.  Virtually no voter will change their allegiance based on the precise nature of Labour's NHS policy next year.  But Labour could get itself into needless trouble by promising the earth, tempting though that must be.  Now one might say: Satrmer is such an accomplished liar and shameless U-turner, he can say whatever he will and then renege on it as PM, just as quickly as he always has with any other pledge or promise he made to the Labour faithful since 2019. 

Still, he'd probably rather not.  Might Labour then be the first party to come to power with a bit of a free hand on the NHS?  We do all really know it can't go on like it is.

ND 

Boris blows it

 Maybe I am a slow learner, I gave the Government a break on Covid. they made some mistakes and more than decisions they got right. But we all make mistakes under pressure (you should see my ever dwindling share portfolio, which I can only make rise in a falling market, sadly the market has been on the up for years).

Brexit too, many of the benefits are just plain ignored by the Remainers in favour of more and more ludicrous stories of empty super markets- the truth as ever is somewhere in between. But the lack of joining EFTA will bug me, as so much of the aggro now we need not have. 

However, the NI tax rise has broken me. Hosing more money on the NHS is insane. The health service is barely fit for purpose and health inflation accelerates away all extra spending. The money taken today won't likely ever really go into social care. 

Social care is a mess, throwing more state backed money at it is a bad idea. It is a mess partly because 90% of the sector is state backed, with all the price gouging, poor service and poor working conditions that usually entails. But Boris wants more of this. 

Boris has lost any kind of ideological compass. This is a Labour policy through and through, so Labour even Ed Milliband would not have tried it. If the Tories want to be Labour, fine, but then we may as well vote for the real thing and be done with it. 

Can the NHS take it?

Herd immunity, a phrase spat out by Beth Rigby and Adam Boulton, is in fact the only route out of our crisis. A six month lockdown is not going to find any obedient takers. There is a small chance people might go for a in and out type strategy where we get sent home again for a few weeks for a week or two out again. This will work better when we have an antibody test.

What I have not seen though, amongst the cheerleading for the NHS, is that when reality hits in a few weeks time, it could get nasty. For lockdown to end, we need to accept ongoing illness and deaths. The NHS workers have to deliver this and risk themselves at the same time. Over time, when they see everyone else going back to normal this will be resented by them - as I would myself.

Where is the danger money? Where is the 💯 effective PPE and process?

Without these it is only a matter of time until the unions strike or the NHS suffers mass illness and nurses and careers stop going to work. I think both of these remedies can be found but they need to be high on the Government’s  agenda. Also it needs to be clear to the public that we are expecting those in the NHS to suffer as footsoldiers in war and to treat them with the respect this deserves.

Self-Sufficiency: Good or Bad?

Our old friend Sackerson and I have periodically debated between ourselves what attitude one should take as regards national self-sufficiency.  On the one hand, to be dependent upon imports for any vital need is to offer a hostage to fortune in difficult times.  The very concept of the nation-state is often identified with this situation.  Only when man (or proto-man) existed in isolated and self-sufficient communities could reliance on trade be thought of as irrelevant.  On this analysis, nation-states exist when, and because of, the move to specialisation and trading, which requires the thus-extended and non-independent communities to organise in such a way as to (attempt to) make this a viable state of affairs.  Sometimes, typically in warfare or conditions of famine etc, such arrangements fail.  History is littered with case studies, Germany in WW2 being a fine example: suppose the Third Reich had been self-sufficient in raw materials ..?  Today, China is endlessly nervous about its own dependencies on imported raw materials - just as we are about their monopoly on rare earths.

On the other hand: given this potentially fatal outcome, why do people surrender their self-sufficiency in favour of specialise+trade at all?  Because it is a thousandfold more efficient to do so - in "normal" times!  Even George Monbiot rapidly tired of life as a subsistence farmer; and many on the green-left reject what is termed "deep adaptation" (= living in caves).  All capitalist instincts (and not just doctrinaire capitalism either) speak in favour of doing what we're good at, and buying those wonderful things someone else excels at.

So - how is the balance to be struck?  How does a government decide what percentage of, say, the country's electricity should be generated within its own borders, or (a similar problem) how many rarely-to-be-used snowploughs should litter one corner of Heathrow airport?  How much Risk Capital should a bank hold?  How high should the Dutch dykes be?  Or how big should be our armed forces, to rectify matters when "normal" affairs get out of hand?  In the abstract:  how much of our resources should be tied up, how much potential comfort should we forgo today, against adverse future contingencies?

Let's cut to the chase: we are on a continuum and there is no definitive socio-economic calculation to be done.  There is indeed a ton of maths and modelling we can do, with Nobel prizes on offer for advances in technical Risk Management analysis - but the basic inputs include critical and wholly subjective judgements**.  So nobody should get hung up over what can be portrayed as, or mistaken for, a science.  Only towards the very ends of the spectrum can anything strong be stated, e.g. (a) the Vatican isn't a viable state, and needs to be embedded in something a lot bigger;  (b) Canada is very fortunately placed, and very unusually so (and even Canada is somewhat parasitic on the USA for defence);  and (c) the dykes had better be higher than the average high-water mark.

Covid-19 makes this otherwise rather academic debate ultra-real; climate change ditto.  (For example: we may note that in some quarters it seems to count as wicked not to be self-sufficient in ventilators and virus testing chemicals; but just fine to depend on migrants to staff the NHS ...)  And when it comes to reordering the world in due course, some highly motivated parties will be competing for control over those "critical and wholly subjective judgements".  

We can at least be grateful they won't include Bernie Sanders^^ or John McDonnell.

ND
____________________
**  Another post, maybe.  I can bore for England on this
^^ Definitely another post!  There are fascinating developments on the lefty front

Boris Shows Up May for the Useless Politician She Is

One of the reasons the Iranian revolution 1979-81 succeeded so brilliantly was that the incoming clerical regime delivered an immediate financial win for the entire population.  This they did by the simple expedient of curtailing the Shah's immense military expenditure and returning the money to people's pockets.  Thus, long before the clerics started on the hateful stuff, everyone had settled back thinking - you know what, this ain't so bad.  It gave them a clear run at what they really wanted to do.

What May ought to have done on her own Day 1 was to declare that the amount of the UK's net contribution to the EU in 2016 would be added to the NHS budget - starting the day we left the EU.   She'd have killed dead the silliest meme she now has to face week in, week out; and she'd have had well over half the population militating to get us out ASAP.

Impossible?  Hardly: that's around £8 billion, and the NHS budget 2015-16 was £116 bn.  What with all the clamour and political blackmail we know she will succumb to anyway, it'll be more than £124bn by 2019 come what may.

Boris' latest self-serving nonsense merely goes to highlight the masterstroke that was available to a creative politician back in summer 2016.  Ah yes ...

Might it still work?  Presumably now, Hammond would stamp his little foot, and that would be that.  He wouldn't have had the chance if it had been on his desk when he first walked into the office.

ND

Campaigning on the NHS, again

So, in an election where the vast majority of the MP's in the Labour Party do not believe in their leader and they have also decided not have no real position on Brexit - what can Labour do...


They can bloody well campaign to save the NHS!


After all, the Tories are going to close the NHS within 24 hours of getting back into power, all nurses will be fired and your gran euthanased to save money, personally, by Prime Minister May and Jeremy Hunt.


This amazing strategy I fear has had limited electoral success, after all this will be the 3rd election in a row that Labour fight almost solely on the NHS and the third in a row they will lose.


Sadly, there is a lot of collateral damage caused by this strategy.


- First of all it embeds in sections of the public the religion of the NHS.
- Secondly it embeds the idea of constant crisis and need for ever more funding.
- Thirdly it makes any non-Labour party forget about major reforms of any sort as they know this will be used against them in spades for ever after.


Fearing  the tag of the nasty party, the Tories say as little about the NHS as possible in any election, it is their weakest ground. I would not be surprised if Jeremy Hunt was sent on a fact finding mission about the obesity crisis in Pitcairn over the next few weeks.


Actually though, in a parallel universe, this election where the Tories will win at a canter, should be the one where they try to speak some sense for the first time....


1. There is not enough money now that new treatments are available and the population is aging. Also, holding down pay was a temporary solution but won't work ad infinitum.
2. We therefore need to both reduce services and increase funding to ensure a stable Health Service.
3. Non-essential services, even tough choices like IVF, become contributory
4. Stupidity - ie admission to A&E blind drunk or with a sports - also result in a bill (O, let's call it what it is, a Fine).
5. All cancers and serious illness to remain free.
6. Health Insurance to be removed as a taxable benefit, to encourage its use by those that can afford private care anyway.
7. Web based doctors assessments to become standard entry point prior to seeing a GP.


Points 2-7  above would result in massive cost savings, none of them involve any sort of dreaded 'Privatisation' and all I predict will be done in the next 10 years anyway - better to be in the front foot. There is no reason Labour have to win on this topic, after all the health service under them was only better because they threw borrowed money at it for a few years and broke the country.

NHS Questions

Finally, Jeremy Corbyn had a good PMQ's today. He managed to focus on the NHS and the Government, as every Government seems too, looked a bit wobbly.


I have 3 questions to pose....


How much extra money has been spent on the NHS since 2010?


How many extra appointments are now needed in addition to service levels 2010?


How many immigrants has the country allowed in since 2010?


I only say google yourselves because my light research was fairly stark in its answer and yet I am sure just asking these questions condemns me to the alt-right loony bin in the eyes of many....

NHS strike - why do this?

I find both sides stance on the NHS doctor's strike hard to fathom. For the Doctors' there is a big risk, that is that they get seen as greedy and get exposed for it.

This has happened in the past, generally nurses, paramedics and firefighters re all everyday heroes beyond reproach. Yet the firefighters managed to strike and lose against a Government in recent times, mainly because their actual hours and pay was exposed in the media; as a result they had to cave into the Government.

This perhaps it is different, although the leaders of the BMA, are hard lefties who think Corbyn is a moderate uncle. As such, their judgement on how far to go has to be questioned.

On the other side, the Government's base case is a 30% effective pay cut due to increased hours alongside a real 11% pay rise. Nobody is going to be happy when presented with that and young doctors are much put upon. Those I know work hard and are paid relatively little; of course in later years this dilemma is reversed.

Which makes me wonder what Jeremy Hunt is doing, the doctor's pay issue lies with another group and there are other ways to create a 7 Day NHS - which in itself should be a very popular policy. As always on health, any reform is met with fierce resistance and any Government has a tough time. Why this fight this fight though with such a weak case. I have seen hardly any justification in the media for the Government position, which generally means they don't have any decent facts to stand their case up and the civil service have left them swinging.

All in all a bugger's muddle, the result of which is if you are reading this try not to get run over by a bus today.

Why do Doctors want to kill the UK?

I have never been a big fan of the medical profession, I remember way back at University being concerned that the medical students I knew were getting by with pass rates of about 60% - so not knowing a good 40% of what they needed too! How was theat going to work out in the future....

More relevantly perhaps is that in recent years the Doctors of the UK have started to make plays which affect and potentially destabilise the whole country.

The first battle was around pay and working conditions. The EU had implemented the working time directive and this made the lives of junior doctors impossible - they had been asked to work crazy 90 hour plus weeks. Also Labour wanted to implement some reforms of the NHS which the BMA was against.

So Labour happily drew up new contracts, which managed to have both shorter hours and extensive 'overtime' for GP's. Doctors were now earning 20% more for doing the same of less work. This at a time when the UK was just beginning to spend more on the NHS but was also starting to run a deficit during the high point of the economic boom.

The second major battle has been around immigration. Not just of actual doctors, which is a separate topic, but of treating immigrants. Doctors have long claimed under the spurious 'hippocratic oath', that they be allowed to treat anyone who appears before them (less than 50% of British Medical Students 'take' this oath anyway). As immigration soared after 1997, so the costs of treating health tourists did too. Doctors want nothing to do with controlling this, but at the same time demanded more money and are always keen to stick the knife into 'hospital administrators.' This classic tactic plays well with Labour who always rant on about how many more nurses and doctors they can have. However, for everyone else, what does it matter if we have more supply of doctors and nurses (and indeed treatments and facilities) if demand grows exponentially.

Then finally today, another example raises its head. David Cameron and the Government are keen to reduce benefits of those who are able to help themselves but choose not to. So targeting Obese people and drug addicts who are in receipt of long-term benefits for their condition. This is not an article about the rights and wrongs of the policy. Here is to show Tory MP Dr. Sarah Wollaston is against this policy as it is not for Doctor's to implement Government policy and not for them to withdraw or prescribe treatments to patients without their consent.

To me this position is untenable, the Government pays the salaries of the public sector and the Government has to balance the books and make hard choices - it is why all Governments are always unpopular after all.

The above three cases show that Doctors consider themselves above the rule of Government despite working for it. The Health budget is 15%+ of Government spending and increasing out of control. Yet it is not for the Doctors to do anything at all to help, except to say 'its not my problem.' For the finances and long-term stability of the UK this is a huge imposition and not one that anyone can do anything about via the ballot box - it is a calissic case of producer caputre.

The Doctors in many areas are hold the future of the Country literally in their hands. This is a huge problem for the Country as they have the power of life and death and are vested with such moral authority - it is a great argument for privatising more of the NHS so as to remove the leaden hand of the Doctors from Government policy.

NHS death service redux

It is really sad to see how difficult decisions can be. I am often reminded of the old Michael Heseltine quote from the 1980's when discussing decline in the coal mining industry - there are no good choices, just bad or worse.

Fast forward to today and we have a big over-spend on unproven cancer drugs. We all know people who have died or are dying of cancer and naturally want the very best for them. The cost is eye-watering and with a £100 million overspend a task force was put in place to review the situation.

It was decided then to reduce spending on expensive unproven drugs and divert the money to more spending on cheaper and proven drugs.

This not controversial in any way, except if you believe in the magic money tree that money is irrelevant and everything should always be done. But if you do that, then after all the reports I have seen on Sierra Leone and the awful situation there, clearly there are greater needs elsewhere. This is where morality and reality clash.

So onto the NHS, Labour - having more or less admitted to 'weaponising' the NHS as part of the election strategy are keen to paint this as Tory cuts. The Tories are keen to point to the independent task for asked to look at this and to the benefits of clinical outcomes.

What is so frustrating is the black and white picture painted at the moment around the NHS. Either it is our national treasure or evil Tories want to destroy it. We have either the UK or US system.

There is no room or political space given to the mixed approaches tried in other countries or analysis of where other countries provide better systems and better care. Just an old, worn out dialectic between the well meaning nanny state or the evil capitalist market.

Ambulance + A&E Crises: A Sorry Tale

The perennial winter 'A&E Crisis' stories are with us again, this time with all-too-plausible rumours of targets and statistics about to be manipulated.  Burnam's response for Labour was very nuanced and oblique, so he's obviously been told by Ed Balls to tread carefully and not make anything that might look like a costly promise to do better if Labour come to power.

One of my nearest and dearest had a 5-week involvement with the NHS a short while ago, including an ambulance service / A&E episode.  I'm only too happy to acknowledge several aspects of the story that reflect well on the services we encountered (because there were some) but, from this very recent first-hand experience, there are some shockingly bad and wasteful practices in the emergency services that need sorting.

At a particular point in the saga a District Nursing team determined that 'immediate' hospitalisation was necessary.  I was actively involved throughout what followed.  The degree of urgency was, it is fair to say, below that of a heart-attack or ongoing stroke, but this was no leisurely admittance.  The 999 call centre said that according to their prioritisation scheme an ambulance would be forthcoming in no more than 80 minutes (stated more than once, in a manner that conveyed a strong whiff of Statutory Target).

After 3 hours, two more 999 calls and no ambulance, a senior District Nurse attended and worked the 'phone to get a bit of priority.  At 4 hours a team of 2 'first responders' showed up.  They made a few simple tests, administered oxygen, and asked a heap of questions.  Shortly thereafter a one-man 'ambulance' turned up - in an estate car jobber that wouldn't ever have been a suitable conveyance.  The new man on the scene brought into the house even more portable equipment and had a load more questions - not directed to the DN or me, but to the first-responders.  Finally, a 'proper' bed-ambulance arrived with two more operatives (and a load more questions, this time posed to the first ambulance man).  More than 3 hours after the 'maximum 80 minutes' we now had 5 NHS staff and 3 emergency vehicles on site, to get one patient into one ambulance . 

I'll maybe recount the A&E saga another time.  For present purposes let it simply be noted that although the (uneventful) 15 minute drive to the hospital allowed the ambulance attendant to complete a raft of paperwork (I was sitting alongside the whole time, answering yet more questions), upon arrival the attendant went to a desk to be interrogated from square one by a reception nurse, going over all the same ground once more (the fourth time).

Let's put to one side the suffering and distress, and address the effectiveness of the operation. 

The first lesson: despatch, deployment and coordination of vehicles, crews and resources wasn't just sub-optimal, it was appalling - how come that after 4 hours we wind up with 3 vehicles plus 'highly-trained' crews, only one of which is actually needed ?  Somewhere in the worlds of, oh I dunno, Air Traffic Control ?  RAF casevac mission control ?  Minicab despatchers?  24-hour emergency plumbing firms?  - there must be people and software that can marshall limited resources a damned sight better than that.  Until the gross inefficiency is sorted, please don't tell us there is a shortage of anything.

Secondly, the transfer of information was worse than primitive, it was utterly ineffectual.  The crazy sequence of chinese whispers conducted right under my nose was an outrage to any system of communication anywhere, any time.  Why, during the first 3 hours, hadn't the District Nursing service equipped the ambulance and A&E services with all the basic info, if only by 'phone?  Why were they asking each other all the same questions in turn? (Well, because they were all there, I guess - and all had log-books to complete in due course!  I'd be interested to compare them all ...)  Why didn't they direct the questions to the horse's mouth?  Why was there such a low level of fidelity in successive verbal transfers?  The number of times I had to correct inaccurate chinese whispers was well beyond a joke, and I shudder  to think what might have happened if I hadn't been standing right there to do just that.  

Finally, why was it all by word of mouth, when at several stages there were really obvious opportunities for bluetooth transfer of digitised info, or at least recourse to everyone using an SMS-based central system?  We all know how quick those systems can be.  The time in the ambulance was essentially wasted, not to mention the consequential waste of time at A&E when both the reception nurse and, perhaps more importantly the ambulance crew, could have moved onto the next job five minutes sooner.   (I might add that within the hospital itself the 21st century has been embraced in this regard: they have got basic single-keystroke and direct-from-sensor info-transfer via hand-held devices down to a fairly fine art - so the understanding and technology do exist in the NHS.)

These basic process-and-systems deficiencies are grotesque, and must in some instances (though not directly so in this case) be life-threatening.  'Soft' issues like suffering and distress are much alleviated by slick, optimised processes.   Costs are cut by eliminating waste - again, via slick, optimised processes.  Everything screams out for this to be brought into line with readily available modern methods.  Shame on the management that soaked up the billions pumped in by Blair and Brown without addressing these basic imperatives.

ND

How can Labour or the Tories fight an election on the NHS?

Westminster, we have a problem it goes like this:

- Current annual deficit - £75 billion, stable and not falling due to a low rise in income taxes

- Total UK debt  - £1.225 trillion and rising rapidly

- NHS shortfall in 2014 - £2 billion

- Predicted NHS Shortfall by 2020 - £30 billion.

- Total Government spend 2014 - predicted £636.6 billion versus £720 billion spending (OBR)

In addition, Mr Milliband yesterday said that he would save our NHS , budget this year £108 billion, from the evil Tories.

And, worse than this, Mr Balls and Mr Osborne are agreed that by 2018/19 the deficit will be eliminated and therefore in real terms we need to have a further £50 billion of cuts over the next four years from 2015. To this we can add the £30 billion of NHS spending.

This £80 billlion is 12.5 of current spending - equivalent to the whole of education and defence spending.

There is simply no way of raising revenues from the economy anywhere near enough to cover this predicted hole in the NHS alone. This is before we add in social care and sweets for all that parties must promise to get elected.

The entire 2015 election according to Labour will be fought on non-economic criteria as they are so far behind on this. But the truth is, even the Tories do not want to fight on the real economic criteria becuase they too know there is no answer apart from drastic cuts to spening. Let's say, end housing benefit and tax credits, plus raise top rate of income tax and a mansion tax, with capital gains at 40%  - this would just about get you to the point where the hole would be filled.

There is a solution of course, end the NHS as it is, focus on people's basic needs and grow and insurance industry out of the nascent one that we have. Make people realise the true cost of care.

To me the NHS, wonderful that it is in so many ways, is the epitomy of the magic money tree theory - worse because we and our loved ones are all mortal in the end. As we have it, it is totally unsustainable without in short order sacrificing much of the national resources into it - but people may vote for that anyway, unaware of the reality for which they are voting.

The 'rich' are jumping the queue.

The 'rich'  are jumping the queue, said Petrie Hoskin on the radio earlier. 
She was referring to the NHS and this ongoing idea of charging everyone in the UK £10 a month to use it. Rich people can go private so, jumping the queue.

Two issues here. Firstly, as we discussed the other day, the £10 extra idea isn't very popular. It will be even less popular when its discovered that it doesn't raise the 60,000,000 x £10 x12,  that its promoters wish. That it won't apply to children, obviously. Or pensioners. Or people with long term health issues. Or people in prison. Or recent immigrants. Or unemployed, disabled, on benefits and every other thing under the sun that excludes someone, usually for a good reason, from paying. As P'J O'Rourke once almost wrote, "When the government says everyone will pay the new tax, they mean its just going to be you and me. And I'm going to weasel out of it on some pretext.. so its just you."

The second issue is that 'the rich' using private healthcare are not, unless you are a Miliband acolyte,  jumping the queue. They are not even in the queue. They are in a different queue. They paid for a ticket to be in the NHS queue but they decided against using it, and so bought another, more expensive ticket, to join the private healthcare queue. They weren't able to get a refund on the NHS ticket.
In fact, instead of jumping the queue , they actual left the queue and so accelerated the queue for everyone behind them. And they paid for a portion of those people's treatment, even though those people now won't be paying a penny for the 'rich person's' treatment.

But we hate the rich, which seems to be anyone earning about £40k, so when they don't take a free to use service that they are entitled to, and instead pay money that has been taxed to access a private service,  they are making the poor suffer. 

Somehow.

NHS: patient fines.

A former Labour health minister has suggested people in England pay a £10 monthly membership charge to use NHS services.

This question came up at Question time. Almost no one on panel or in audience agreed with it. rightly too. An Extra £120 from every adult in the UK is some tax! But many did agree that something should be done.

Charging for appointments was immediately out. Free at the point of use and all that. {Why don't we care that we pay to see a dentist? We hand them cash and don't even think about it.}
But the idea of fining people seemed quite popular.  Not the A&E drunks and druggies or 50 fags a day heart failures and the fat to walk types.  More the inconsiderate. The  people who don't attend an appointment. The people who don't finish their course of prescriptions. calling an ambulance for a splinter and such. 

On appointments 3 times missed to be a fine was suggested. 3 times seems absurdly generous considering 99% of the nation, including children, have a mobile. Its only a call to say can't attend. Maybe a text/email line would help? 
The reality is it often takes two weeks to get an appointment by which time a % of people feel better and have forgotten all about it. 

But it is an easy one to implement. Appointments are recorded already. A second data file to record who hasn't attended wouldn't be hard to add. And a £10 fine or exclusion not too onerous for anyone.
Remember, its not for cancelling an appointment but for not turning up and telling anyone. And schools fine parents £80 for taking a term time holiday. The council will slap £120 if you accidentally put glass in the tin recycling box.  Its £60 for 3mph over the speed limit.That is to encourage responsibility, so government says.

£10 a sinner won't raise any money. maybe make it two tenners? And all the £10's can go into a staff Xmas bonus fund to make sure that the receptionists collect them. It would set a precedent. For the courts. For social worker visits. Local authority repair works.. .

 And the NHS is the most expensive thing we have in this country. Shouldn't we at least try and make people respect it a little more?

Stuffing the Doctors' Mouths with Gold - Again?

You have to hand it to the medical profession.  Really: I mean, you just have to.  Hand it over.  It's the only way to get them to do, well anything.

When Nye Bevan was asked how he managed to win the doctors round to cooperating with the creation of the NHS he famously replied that he had "stuffed their mouths with gold".  Yes, the doctors always have a pragmatic solution on offer. 

This time, with winter coming on and heating bills on the front pages for weeks, suddenly we are warned that A&E will be chokka with the elderly as soon as it turns cold.  Disaster for the coalition looms. But what's this, do we hear the clinical cavalry riding to the rescue ?  Yes, right on cue the doctors are to get new contracts, under which, says Jeremy Hunt "all NHS patients over the age of 75 must be assigned a named, accountable GP who will oversee their care".

Remarkable !  Is there an over-75 in the land who doesn't have a named GP ?  Is there anyone ?  (Aside from those not actually eligible for NHS care, who just stride into A&E or a walk-in centre anyhow.)  And does this mean house visits as in days of yore, or out-of-hours attention from the GP ?  Errr, no - but the GP must 'monitor the effectiveness' of other agencies' out-of-hours provision.  That'll keep the over 75s in their own beds.

And for this new contract, minister, what about the money you'll be giving them?  Turns out, that's not what we might call transparent: it's certainly not mentioned in this short guide to what's going on.  Or this one.  And Jeremy Hunt is a bit oblique here, too.  “The public will know what salaries GPs are taking home for NHS work. This will give the Government more confidence to hand more funds to GPs in future.”  

And the timetable for all this change ?  Will it be in place by, say, the end of the month in time for the really cold weather ?  Nope: it commences April 2014.  And publishing the salaries ?  That'll be 2015-16.

MD  ND 

NHS - there may be a way out of this

Miliband told the chamber "Another area he is in a complete mess is his health plans."
"We all remember the PM touring round the country promising no more top-down reorganisation of the NHS… I'll tell him why he made promises that he broke: because he is completely shameless and he will say anything. However much he says he loves the NHS… the truth is that he's got the wrong values... He's been found out. We know all we need to know about this prime minister from the NHS, he's reckless... He's proved the oldest truth in politics... You can't trust the Tories with the NHS."

And that was PMQs from a year ago. David Cameron spent years and years trying to reassure the public that the horrid Tories didn't really hate the NHS. They loved it. If there was one area not to have even spoken about in public, this was it. Because the trust was a fragile as a newborn.

Very early on I said that no good could possibly come from a reorganisation of the NHS. Its such a vote loser. I urged the government to drop the bill. Readers here were pretty scathing of my suggestion. Demanding waste, inefficiency, bloated bureaucracy, self interest, huge costs and poor performance be tackled at once by the government

My arguments that the government had already too much on its plate, what with tackling a £35 billion defence black hole. A justice reorganisation. Tuition fees. Welfare and benefits caps. A completely new proposal for schools. Fundamental changes to the tax system. A localism bill. Public sector pensions. Private sector pensions. Union membership at taxpayers expense. A boundary election review. An Av referendum. The so far untackled, but pre election bombshell of provision for the elderly. The privatisation of a crumbling mails service. Council tax capping and many , many more.. any one of which could be a central plank for a reforming government.

And all this planned during the worst recession for 80 years. Without the money to ease change or buy out the vested interests. With minimum 5% cuts across all departments. With rising taxes and rising inflation. Rising borrowing and rising unemployment. Whilst students protest in the streets and looters smash up shops. With the Arab world breaking apart. And the Euro in almost terminal crisis.
And the usual terrorism and violence continuing on. While politicians are not forgiven for their expenses crimes. And phone hacking neuters a normally friendly press. And recession makes the country grow ever more socialist, demanding that all must have everything or all must have nothing. With an ongoing, unresolved world financial banking crisis in play.

All this.. and yet the government thought tackling the world's 7th biggest employer, {- just behind McDonald's who operate in 119 countries not just the one} in which almost every household knows someone or has someone working for the NHS {McDonalds has some 67,000 employees in the UK compared to the NHS' 1.4 million. or 1 in 25 of the population.}

Tackle the NHS ? Whilst in a liberal coalition? With no majority? During an Olympic year?
Are you stark staring raving mad?

No government should attempt a top down reorganisation without a lot of time, a lot of money and a large majority. And not in the first year either as its going to need people used to government office and media to even begin to move the behemoth.

I knew it couldn't just be me thinking this. And so its proved with even some Tory cabinet ministers demanding the government put a stop to it, for purely political reasons. They are acutely aware that they are handing the floundering Milibandwagon its next government kicking opportunity. Miliband has even got a slogan out. "Ban the Bill." Quite catchy. it'll be a ringtone next.

Naturally I agree with those rebel ministers.

Politics is the art of promoting the possible and avoiding showing the unpalatable in public.
This Bill will only become more toxic. I confess I don't know anymore of the details than can be read in the telegraph. Its not the details that matter. Its the politics. As Tim Montgomerie's explosive call for the Bill's end perfectly demonstrated. He calls Mr Cameron to choose two paths - The watering down one. Or the pushing on into the minefield one. Already Conservatives have turned on Tim and are manning the barricades against any stop to the bill. This is just politicians unable to face a very tricky 'retreat whilst in engagement with the enemy,' dreaded by Generals and Prime Ministers because of the inevitable casualties and morale loss such a manoeuvre brings.
The government has got itself into a mess. Possibly a fatal one.

But there is a clear strategy out of this. One that might even strengthen the PM, rather than weaken him, after the initial pain.

1. Agree to a second look at SOME of the proposals, as Mr Montgomerie suggests. Especially bringing in Liberal Peer Shirley Williams and possibly Lord Ashdown and others who feel a sense of having collaborated too much with the enemy. Make sure Clegg has some role too.

2. Agree that more cross party talks are necessary and invite Labour to share in those most likely to pass the Lords.Make Labour a part of it. If they won't join, great. Ask for their non existent solutions each time they criticise.

3. Lansley has to go. Quietly if possible. Bloodily if not possible. Now who to replace him with?
A lib dem would have my fellow conservative backbenches screaming in rage. But its such a smart move.
A liberal tackling health reform takes the Tory Toxicity charge away immediately. It reassures the public. It allows the doctor's and nurses medical boards and unions and government to begin again. Clean sheet. Who it actually is is the hard part. I propose..

Vince Cable!

Jim Hacker would have spotted the master stoke this really is. The most undeserved promotion in history. "But merited;thoroughly merited, my dear chap."
It removes a poor business secretary to a high profile place where the outcomes have already been decided and the political losses written off. It makes room for David Laws to come back in a role that may well suit him at business.

4. The reforms will have to be watered down. There is no alternative. But that doesn't matter. Pick the red lines. Two years of parliamentary time's worth, and sacrifice the rest under a rearguard of amendments and negotiations.

5. Whatever the outcome the Liberals will have had a major success. One that they can genuinely put on their leaflets. "We saved the NHS." It allows the Tories weak, Italian style allies, to get a victory and a purpose inside the coalition. It will gladden the activists hearts.

6. The conservatives gain too. "Listening" Dave is back. He can claim to just be doing what the public and professionals want. "Tough choices have to be made, and will be made! Let there be no illusions. But in light of some recent discussion with hardworkingdoctors'an'nurses and with the help of a cross party/ coalition group i feel we've really got something that will make the NHS even better than ..blah blah blah." You know the shtick. Sleeves rolled up. Tie and jacket off in a health centre somewhere. . no notes. He does it very well. Caring conservatives are back to help take the focus of all the other uncaring policies that have to be put into place.

7. The success of the NHS may just save the Liberals who have made so many stupid 'no top down reform' type pledges of their own over the years they don't deserve saving. But in practical, reality land, a coalition again is a very likely possibility.
If the Liberals feel they have genuinely achieved something. Have genuinely influenced Tory policy. Are a 'force for good' within the evil Tory galactic empire, then so much the better.
Labour are going to claim the reforms are a failure whatever happens to them anyway. Labour are irrelevant.

Let the baby have its bottle. Vince Cable for the mediating Health Secretary!

Meanwhile the government can get on in peace with its brimming over plate of other, even more difficult issues.


That shiny new 1960's hospital in the picture at the top is from Carry on Doctor. Its actually Maidstone Town Hall.

"Health Bill proposes turning hospitals into tax buildings!"

That's the sort of made-up headline Mr Miliband's people are just waiting to write, Dave.
For the next two years - one a day. Fed to the Guardian and BBC and injected into the nations psyche.

Can't say you haven't been warned.