The TaxPayers' Alliance - Better Government

Priorities in Government

There are two issues in the news today that deserve a prompt and serious response.  Hospital infections are proving more lethal than we thought:

"Nearly 10 people are dying every day from the superbug Clostridium difficile.

Official figures show 6,480 death certificates in 2006 mentioned the bug, compared with 3,757 the year before - a rise of 72 per cent.

The increase comes after the Government told doctors in 2005 to note healthcare-acquired infections on death certificates."

And:

"The quality of education in primary schools has worsened under Labour despite increases in funding, says the biggest inquiry of its kind for 40 years.

Reports published today say many pupils spend too long preparing for "batteries of tests" in English and maths at the expense of a broader education. The reports say educational standards may actually have fallen as a result.

In one study, it is claimed that Government control of state schools has risen over the past 20 years but "especially after 1997"."

These are the kinds of issues - the life and death struggle to control hospital infections and the future of an entire generation - that Government should be worrying about.  With a massive concentration of power and responsibility at the top the attention of the Prime Minister should be focussed on matters like these.  Instead, Gordon Brown is concerning himself with plastic bags:

"Gordon Brown has warned supermarkets he will force them to cut down on the number of plastic bags they give out if they do not take steps voluntarily."

It's like Northern Rock's Chief Executive choosing to spend his time scrutinising orders for paperclips.

A third of pupils failing in core subjects

Some rather dispiriting news today about the number of students still failing to meet basic standards in the core subjects:

"More than a third of schoolchildren in England are failing to master the basics after three years of secondary school, according to results published today.

Around 216,000 struggle in the core subjects of English, mathematics and science in tests taken aged 14 - seen as a key indicator of success at GCSE.

According to official data, the number of pupils reaching the expected standard in maths dropped compared with a year earlier. Results in English were no better than in 2005."

Politicians have had nearly 130 years to get the education system right.  How many more young people are we going to allow to be let down by the politicians who think they can run schools from Whitehall?

Amateurish politicians and unintended consequences

Be very careful of assuming that if someone's heart is in the right place they'll tend to get things right.  They need to know what they're doing.  Here's one example, from the Marginal Revolution blog, of what happens when they don't:

"Oakland's recent gun buyback was especially ridiculous.  The police offered up to $250 for a gun "no questions asked, no ID required."  The first people in line?  Two gun dealers from Reno with 60 cheap handguns.  Fortunately the buyback did manage to get some guns off the street, too bad they were turned in by a bunch of senior citizens from an assisted living facility.   Whew, the streets are safe at last.

[...]

Imagine that instead of guns, the Oakland police decided, for whatever strange reason, to buy back sneakers. The idea of a gun buyback is to reduce the supply of guns in Oakland. Do you think that a sneaker buyback program would reduce the number of people wearing sneakers in Oakland? Of course not.

All that would happen is that people would reach into the back of their closet and sell the police a bunch of old, tired, stinky sneakers.

Gun buybacks won't reduce the number of guns in Oakland. In fact, buybacks may increase the number of guns in Oakland.

Imagine that gun dealers offered a guarantee with every gun: Whenever this gun gets old and wears down, the dealer will buy back the gun for $250.

The dealer's guarantee makes guns more valuable, so people will buy more guns.

But the story is exactly the same when it's the police offering the guarantee. If buyers know that they can sell their old guns in a buyback, they are more likely to buy new guns. Thus the more common that gun buybacks become, the more likely they are to misfire...."

Leaving the country

When economists want to know what people think they try to avoid relying upon asking them.  Surveys, opinion polls, personal anecdote and other ways in which people express their opinion can often be misleading or distorted.  When and how a question is asked and how it is phrased can seriously affect the outcome of a poll.  More importantly, people may express a certain preference in a poll but make quite different choices when asked to make real decisions with real consequences.

It is often better to look at revealed preferences; how people actually behave when faced with actual decisions in real life rather than hypotheticals in a survey.

Some dramatic new evidence of this kind emerged yesterday.  High staff turnover often suggests that an organisation is not a pleasant place to work.  High numbers of asylum seekers from Venezuela suggest that Hugo Chavez's rule is not very pleasant.  The Army's recruitment and retention difficulties suggest that the poor management of the Armed Forces is making them an increasingly unpleasant place to work.  In that light, the evidence yesterday that Britain is facing the biggest brain drain in 50 years, that those most able to leave are doing so, is an alarming suggestion that things are going very wrong in Britain today:

"There are now 3.247 million British-born people living abroad, of whom more than 1.1 million are highly-skilled university graduates, say the researchers.

More than three quarters of these professionals have settled abroad for more than 10 years, according to the study by the Organisation of Economic Co-operation and Development (OECD).

No other nation is losing so many qualified people, it points out. Britain has now lost more than one in 10 of its most skilled citizens, while overall only Mexico has had more people emigrate."

Why are people leaving?  One suggestion:

"Prof David Coleman, of St John's, Oxford, said the brain drain was "to do with quality of life, laws and bureaucracy, tax and all the rest of it"."

Ever higher levels of tax; little to show by way of public service results for that huge drain on private incomes; an overly meddlesome state that leaves people bereft of control over their own lives.  Yesterday's emigration numbers should be a wake-up call for a nation whose government is attempting to do too much and doing a very poor job of it.  If things don't change Britain will continue to lose far too many of its best and brightest.

£30 billion spent on private healthcare

A recent report from the Reform think thank suggests that UK households spend an average of £1,200 a year on private health care. This amounted to nearly £30 billion in 2007.

While much of this spending reflects the needs of families caring for disabled or elderly relatives, undermining the notion that the NHS remains a 'free' service, a significant proportion is spent by people in need of treatment being forced into the private sector, frustrated with the limitations and inadequacies of a centrally administered NHS.

The spending on private health care illustrates the reality that people are beginning to vote with their feet, the last option left to them when both political parties seem determined to preserve a crippled and failing public health service.      

How to 'free the NHS from government interference

The Telegraph reports a call by the British Medical Association for NHS independence:

"An NHS constitution should be used to free the health service from the day-to-day interference of Government ministers, doctors' representatives have claimed."

We absolutely agree.  However, if you're going to make the NHS independent there are two things that you need to do at the same time:

1. Decentralise.  While a NHS board might have more healthcare experience it would operate from the centre, probably from Whitehall, so could quickly become out of touch with the priorities of local healthcare organisations.  We should give real freedom to local organisations that can respond to the needs and circumstances of their area.
2. Allow competition.  An independent NHS can't mean that producers are left to spend billions of pounds without proper accountability to the public who use and fund the service.  Ordinary people should be able to, through the threat of taking their business elsewhere, hold providers to account themselves.  Healthcare systems in continental European countries reap the benefits of competition, particularly in the Netherlands, without compromising universal service.

If the BMA will sign up to those principles we'll support their call for NHS independence wholeheartedly.

The Government's Northern Rock agenda

Vince Cable, in yesterday's debate on the bill to nationalise Northern Rock, framed the essential question that the Government are not openly addressing but that is of paramount importance to the question of where Northern Rock goes from here over the next few years:

"May I return to the central question of what kind of bank will now operate? Will it be built up or run down? The hon. Member for Newcastle upon Tyne, Central (Jim Cousins), with whom I have had several exchanges in the past few weeks, put it rather well yesterday when he asked whether this is the end of the beginning or the beginning of the end of this bank. That question is crucial. It is at the heart of the argument about the business model, on which Ron Sandler will presumably be asked to decide. It is not clear to me which of the two approaches is the better. A wide range of options exists, so one can envisage a kind of continuum, at one extreme of which the bank would be run off and would have no new business. The other extreme might involve a highly expansionary strategy—a kind of publicly owned Virgin or “the people’s bank”, as somebody called it yesterday. Alternatively, something between the two might happen." - Hansard, 19 Feb 2008 : Column 193

The agenda that the Government are trying to slip under the radar is something closer to the latter that the former; a highly expansionary strategy.  Jim Cousins provided an illustration of the political pressure that the Government are under to deliver such a solution to the problems of Northern Rock:

"Let us be fair about this. Northern Rock was trying to be a big bank based in the north-east that could take on the big boys of the banking sector. That prospect, from the north-east’s point of view, must be retained. It may not ultimately work out that way, but it must be retained." - Hansard, 19 Feb 2008 : Column 198

Cousins is supporting nationalisation because he believes that it is a vehicle for taxpayers' support to be used in an attempt to revive the busted Northern Rock.  Why does he believe this?

Such a strategy wasn't mentioned in Alistair Darling's speech and is hardly the impression given by his rather humble talk of "temporary public ownership". John Redwood asked whether the Government had told Cousins that they were going to attempt to run into reality his vision of nationalisation reviving Northern Rock as a big bank:

"Mr. Redwood: As a local Member for the business, has the hon. Gentleman been given any assurances by the Chancellor that he is going for the growth model and not the wind-down model?

Jim Cousins: No, I have had no such assurance; nor, at this stage, would I necessarily look for one. We have had from Mr. Sandler clear comments that he sees the business as a going concern and is preserving the option of growing it on." - Hansard, 19 Feb 2008 : Columns 197-198

If Cousins is representative then Labour MPs share our conclusion that Ron Sandler's unguarded statement on Monday (quoted in the Financial Times) offers the best clue we have yet to the objectives that will inform the business plan for a nationalised Northern Rock.

"The aim is to reinvent Northern rock as a 'profitable, vibrant and sustainable business'"

This is the agenda that the Government won't yet discuss openly but that seems to be underlying their policy on Northern Rock.  Taxpayer support is to be enlisted in an attempt to revive the bank.  There are a number of issues with this:

1.  It ups the ante by committing taxpayers money to the risky venture of trying to revive Northern Rock instead of taking the more cautious approach of trying to get value from the assets as they stand.  As Stephen Dorrell put it: "The state would be used as a sort of turn-around venture capitalist" (Hansard, 19 Feb 2008 : Column 200).  The ill-fated Phoenix Consortium attempt to turn around Rover as a mass-market car manufacturer shows the risks of a hubristic failure to accept that a company has had its day and might need to be wound down.

2.  Regardless of Ron Sandler's abilities he will be operating a nationalised industry and subject to the political pressures that make the lives of many brilliant private-sector executives' lives hell when they switch to the public sector.  Jack Lemley, the project manager brought in to run construction of the London Olympics venues, told the Idaho Statesman:

"Well, I’ve never walked away from a project ever until I retired from the London 2012 programme, and it was so political that I think there is going to be a huge difficulty in the completion both in terms of time and money and it’s much more difficult because there’s so much time being lost now. [...] I don’t want my reputation ruined being able to deliver projects on time and on budget."

3.  This will be a massive market distortion.  There will be one player in the mortgage market with a guarantee from the taxpayer behind them.  This will allow the bank to offer more generous interest rates than its competitors.  Potential competitors with a revived Northern Rock are rightly furious.

The Government are deliberately keeping the plans for what happens next with Northern Rock obscure.  However, their plan to make taxpayers play venture capitalist trying to revive a busted bank with a wrecked brand is becoming clear anyway.  It is a political agenda that puts taxpayers' money at huge risk and could create damaging distortions in the British economy.

What the opposition should say in the Northern Rock nationalisation debate

The Government offered every inducement to private sector bidders for Northern Rock.  It offered a heads you win, tails we lose deal whereby the taxpayer would foot the bill if things went wrong at the bank but a new owner could walk away with big profits if things turned around for the better.  They still couldn't find a private sector bidder able to offer good value to taxpayers.

That the Government could not find a bidder despite lowering the bar so drastically suggests that the private sector didn't expect to be able to get much value out of Northern Rock.  We are now expected to believe that the Government can do a better job - can deliver taxpayer value where the private sector couldn't.  Taxpayers are understandably cynical.

There are several unanswered questions.  Just how strong is Northern Rock's loan book?  How well prepared is it to weather weaknesses in the housing market and still pay off massive loans to the taxpayer?

What will we have to pay shareholders?  Is there any chance that the outrageous demands for £4 per share being made by hedge funds, who have bought into Northern Rock since the crisis, will be sated?

Bigger questions are raised by the form that this nationalisation is beginning to take.  While this is, in theory, a debate on whether or not to nationalise Northern Rock that is less a decision than a resignation that there is little other alternative.  By contrast, the form of nationalisation is a decision firmly within the Government's grasp and one that could have vast financial consequences.

We can understand how that decision has been made by listening to Ron Sandler, the new boss at Northern Rock, who was quoted in the Financial Times as saying "the aim is to reinvent Northern Rock as a 'profitable, vibrant and sustainable business'".  The Government have chosen not to take the option of running down the mortgage book and steadily putting the bank out of its misery.  Instead, taxpayers are being asked to support an attempt to resurrect the bank.  There are many parallels to the Phoenix Consortium's promise to make Rover a world-beater again.

Such an endeavour is necessarily more risky and involves a greater exposure of taxpayers' money than running the bank down.  The Government is upping the ante on taxpayers' behalf.  While there has been an attempt to spin this 'temporary' settlement as a very short-term arrangement Ron Sandler has acknowledged that it is likely to be years before a resurrected Northern Rock is likely to be ready to return to the private sector.

Throughout that period each British taxpayer will, effectively, have £3,500 staked on the future of a mortgage bank with a busted brand.  Beyond that, they will have to hope that this bank is really run on commercial, and not political, terms.  While Ron Sandler may be impeccably qualified he will be employed by, and answerable to, politicians.  If they see some short-term political advantage in delaying, for example, important decisions on downsizing Northern Rock will the chances of taxpayer value being delivered be further imperilled?

There are other costs to a nationalisation that aims to reinvent Northern Rock.  It will mean facing other mortgage lenders with a rival able to call on a guarantee from Her Majesty's Government.  That is quite a luxury and, in a time when banks are struggling to raise finance, will make it hard for other banks to compete.  For that reason European authorities are likely to take a dim view of overly ambitious proposals to revive Northern Rock.

It is a betrayal of basic economic principle and the interests of every taxpayer for the Government to use Northern Rock as, perhaps, the most expensive job creation scheme in history.

Talking to Friction TV about Northern Rock

Multi-tasking Government

Two stories today, both from the Telegraph.  First, we are a 'soft touch for terrorists' because of a failure to tackle unintegrated immigrant communities:

"Britain has become a "soft touch" for home grown terrorists because ministers have failed to tackle immigrant communities that refuse to integrate, warns a report released today.

The Royal United Services Institute (RUSI), a body of the country's leading military and diplomatic figures, says the loss of British values and national identity caused by "flabby and bogus" Government thinking has made the country vulnerable to attack from Islamic extremists."

Second, one million elderly people's needs are being ignored by the authorities:

"More than a million elderly people are being ignored by the Government and local authorities, and for many, services have got worse since Labour came to power, a new report claims today.

One in five over-80s are suffering from severe social exclusion, cut off from other people and largely neglected by the state, according to the charity Age Concern."

What these two challenges, from major new reports both published on the very same day, illustrate is that Government faces a massive range of challenges.  Is it possible for a monolithic organisation, with a single head, to respond to all of these?

Particularly when that organisation is highly centralised with the single leader (Brown) stepping in to deal with problems of specific briefs (for example, his recent interventions into health care policy).  Of course Government will neglect important priorities when there are so many it has to keep on top of.

Two Newcastles

Another example of ludicrous managerial incompetence.  Why on Earth should we trust these people with children's education, our healthcare and our money?

"Bungling Whitehall officials got their Newcastles mixed up and gave £2.7 million meant for the North East city to its namesake in the Potteries.

Newcastle-under-Lyme, population 74,000, was handed the cash instead of Newcastle upon Tyne, the regional capital of the North East. And the Staffordshire market town is refusing to hand back its windfall from the Department for Communities and Local Government, saying it was accepted in good faith.

"We assumed it was in recognition of the work we've done to encourage business," said Simon Tagg, the borough council leader."

Yet another attack on middle class parents getting the best school places

This time it is the Centre for Economic Performance at the London School of Economics arguing that the middle class are securing all the best school places.  Is it just me or have there been a lot of these studies?

There seems to be one almost every fortnight.  They all make exactly the same point.  The middle classes are getting places in the best schools by playing the system better.  I have no idea why so many researchers from so many think tanks have decided to address the same subject in such a similar way.

Presumably they think that if this kind of study is carried out often enough people will get the message and support lotteries for school places.  What they don't realise is that it isn't an ignorance of the problem that causes people to find their proposal unconvincing but a different analysis as to the best solution.

Lotteries are an admission of failure.  An admission that we can't find a rational way of allocating students to schools and are going to settle for complete irrationality.  Instead, we should look to make it easier for parents to choose the right school for their children, so it isn't only those who can afford to move into the right catchment area or pay for private schooling who have choice.  Greater choice, and greater competition can drive up standards in all schools as students are no longer trapped by poor fortune into a failing school.

The culture hour

"Schoolchildren will be taken to the opera and theatre under plans to offer all teenagers at least five hours of culture a week."

Whether or not an hour of culture a week, as proposed by Andy Burnham and Ed Balls, is really a good idea for students is a question it will be hard to study empirically, even after £10 million is spent on pilots.  There may not be a single answer for all parts of the country, all schools or all students.  Politicians in Whitehall stand no chance at all.  Why exactly is Andy Burham, in yet another target culture initiative, wading in and deciding on the requirements for cultural education across the entire country?

This Government's absurd attachment to centralising schemes appears to know no bounds.  Teachers, children and taxpayers all pay the price.

The £180 million overcharging bill

The BBC reports that the NHS has spent £180 million compensating patients wrongly charged for long-term care:

"Patients charged for long-term nursing and social care from 1996 to 2004 have been able to have their cases reviewed if they feel they were overcharged. This has led to over 13,000 claims and 2,000 pay-outs, costing £180m. The claims relate to the way different health authorities charged for care needed because of illness, disability and continuing NHS treatment.

This "continuing care" used to be effectively classed as social care and as such was means-tested. But a legal challenge in the 1990s led to health bosses being told to fund care packages where the primary need was health, rather than just basic personal care such as helping dressing and washing. However, the rules were interpreted differently across the country. This proved particularly controversial and stories emerged of patients having to sell their homes to fund care - hence the high figure for the pay-outs."

This failure to properly understand what a health authority is expected to deliver is a failure of management.  Managers in the NHS, many of them very well paid, should be able to establish the specifications for their service.

Failure to meet standards for care provision has proven expensive for the taxpayer.  Reviews and compensation proceedings are rarely cheap so not providing care in the first place won't have saved money.  It has also dealt a particularly telling blow to vulnerable people forced to sell their homes or make other sacrifices that they should not have had to make:

"And a spokeswoman for the Alzheimer's Society added: "The charging for care caused a lot of heartache. People had to sell their homes and go into debt. "

Hospital malnourishment

The Telegraph reports on an increasing number of people leaving hospital malnourished:

"The number of patients leaving hospital malnourished has almost doubled in a decade, with one in five now affected, experts said yesterday.

Some 140,000 people are discharged from hospital while underweight every year, and most are never diagnosed or treated, nutritionists warned."

This is just dismal.  Back in the nineteenth century keeping people well fed might have been a serious logistical challenge, in some developing countries it - sadly - still is.  Equally people in the UK might not choose to eat the right food and wind up malnourished.  There is no acceptable reason why people in a wealthy country like the United Kingdom in the 21st century, while their diet is provided to them by a hospital, are malnourished.

Food isn't that expensive and the National Audit Office believe (PDF) that the public sector, in general, can feed people better while spending less if if tightens up the management of its food procurement so there is no reason to see a lack of funding as the problem.  The NHS can find room in its doubled budget to feed people properly. 

The problem is that the way the NHS is organised encourages healthcare professionals to ignore the issue.  As monopolies NHS Trusts don't have to appeal to patients but to politicians and Civil Servants.  Working in a bureaucratic machine they have to respond to Whitehall's priorities.  Taking the time to feed a patient or putting management effort into improving the quality of meals is a distraction from the unending job of meeting the targets and improving the statistics that are the only way centralised politics can understand quality and efficiency.

Malnourishment in hospital should be consigned to history in the UK by now.  It hasn't been because, while medical science is constantly innovating, the organisation of healthcare delivery is failing to progress.  We need to learn lessons from other countries in Europe that avoid the centralisation and political management that results in organisational failure in the NHS and malnourishment in hospitals.

Public sector staff shortages

The Guardian reports on threats of a teacher shortage:

"Schools will face a shortage of maths and English teachers next year, new figures reveal. They show a dramatic drop in the number of teacher trainee applicants.

The number of applicants to start postgraduate teacher training for primary and secondary schools this September has fallen by 9% compared with this time last year, the figures show.

The most dramatic falls are in physics (30%), maths and English (15%), information and communications technology (16%) and geography (14%)."

There have recently been similar stories of staff shortages in the armed forces and the health service - with GPs threatening to leave the country.  Is there a common reason why the public sector is finding it so difficult to recruit necessary staff?

A lack of professional autonomy is widely understood to be a major source of workplace stress, from BusinessLink:

"Where possible give employees more autonomy, allowing them to plan their work schedule and decide how to tackle problems."

Working within the bureaucratic public services people have far less autonomy.  Accountability to customers or specific objectives is replaced with hierarchical control.  “Good people, good systems:  Former public servants talk about delivering public services in the private sector” from the Serco Institute contains plenty of anecdotal evidence on the difference:

"‘Implementing change is much quicker.  In the private sector, you have the capacity to change quickly and to react almost instantaneously.  But it is left to individual [contract units] to react to the changing pace of the [customer] – head office is behind on these development most of the time.’

‘In the public sector if you wanted to change something, you would have to put forward a business case, which would then go to [the public sector organisation] board level and then be negotiated with the union.  It would take a long time.’

‘I am free to manage with greater autonomy, most certainly.  But that freedom comes with a price.  If you get it wrong – I’ve always accepted that if I’ve made a mess of my job I will be called to account at some stage.  It doesn’t have to be a nasty falling out; it’s just that if I run this contract and it doesn’t go well – either because we lose a lot of money, or the client is permanently unhappy with us, or we have a terrible safety record – it’s quite right that I should be called to account.’"

If public services can be freed from political management then not only can those services improve but staff can be better off - enjoying greater autonomy to get on with their jobs.  We will all benefit if that makes recruiting quality staff to the public services easier.

Police paperwork cuts - we'll believe it when we see them

The Telegraph reports on a leaked draft of a report that will call for significant cuts in police paperwork:

"An official review by Sir Ronnie Flanagan, the chief inspector of constabulary, says police have become ''slaves'' to rules and regulations and are ''strait-jacketed by process".  His report was delivered to the Home Office on Tuesday night and a leaked draft shows ministers are preparing to publish plans for reducing the paperwork that has overwhelmed the police in recent years.

They will include abolishing the ''stop and account'' form that takes 10 minutes to fill in. Instead officers should hand a business card or something similar to the person they have stopped ''as a record of the encounter''.

Personal details of anybody they stop and search could be logged on hand-held computers and sent directly to the police data bank.

Sir Ronnie says his ideas could save up to six million hours of police work a year."

Sounds like pretty good news, doesn't it?

We'll believe it when we see it.  So long as the police are accountable to politicians in Whitehall rather than the people in their local communities there will be a powerful incentive for them to engage in bureaucratic box-ticking.  Creating a statistical illusion of activity to keep politicians happy rather than deterring and combatting crime.  We might well find that abolishing the stop and account form just gives police officers more time to spend pursuing nonsense cases to keep their numbers up - see PC David Copperfield's book Wasting Police Time for more details of how that fudge works.

One warning sign that the report might not be quite as revolutionary as it sounds is the claim that it will "free 3,000 officers for front-line patrol duties".  That would certainly be good news but there are 140,500 officers across the country.  There is also evidence that time is being wasted on a massive scale at the moment, last year the Telegraph reported that only around 13 per cent of officer time was spent patrolling the streets while 20 per cent was spent on paperwork:

"In 2006/2007, the average police officer in England and Wales - including beat Pcs, traffic officers and detectives - was out on the streets for 13.6 per cent of their time, while paperwork accounted for 19.7 per cent, with 11.4 per cent of that taken up with "incident-related" forms.

The balance has deteriorated since 2004/2005, when patrol time was 15.3 per cent and paperwork was 18.4 per cent, including 9.9 per cent spent on incident-related bureaucracy."

If you cut the amount of time spent on paperwork in half - 10 per cent of their day is still a lot of time for form-filling - you could save 10 per cent of total police time.  That would be the equivalent of freeing 14,050 full-time officers for front-line patrol duties.  Hopefully when we see the final version of Flanagan's report it will be that ambitious.

Photo by Flickr User hugovk used under a Creative Commons License.

Should taxpayers care about other people's obesity?

In a debate over anti-obesity policy at CentreRight.Com Peter Franklin argued that the problem of obesity cannot be ignored because of "the long-term consequences that will be visited upon the taxpayer for decades to come". Peter Cuthbertson responded that, although he also thought tackling obesity would be great, he didn't think Government intervention stood much chance of success. He also noted that obesity might not cost the taxpayer at all according to new research quoted in the Telegraph.

The new research suggested that the obese actually save health services money as they die earlier and from less lingering diseases than Alzheimer's and Parkinson's - which create far more expense. In response, Peter Franklin argues that "these sort of studies are as selective as they are cynical", "did not take into account the social and economic costs of ill-health in younger people" and even "the Dutch academics who authored the study [in] question admitted that "their research did not look at the total costs of obesity and smoking, just the narrowly-prescribed health costs.""

He has utterly missed the point. If the Dutch academics are right that health costs are not increased by obesity then his original contention that there are consequences that will be visited upon the taxpayer is massively undermined. The social and economic costs that the Dutch academics did not cover are mostly not costs to the taxpayer." Absences from work due to illness and employment difficulties" are important but apart from a pretty marginal effect on economic growth their cost to taxpayers will be minor.

While I'm sure obesity is a very bad thing, thanks to those other costs, if taxpayers aren't going to foot the bill an appeal to their interests should not be used to support government lifestyle interventions.

Hospital hygiene - A matter of management

It emerged today that the Healthcare Commission has found Bromley Hospitals NHS Trust guilty of serious breaches of the hygiene code.

Following a series of (all too rare) 'unannounced' visits to the Trusts Hospitals, inspectors reported 'thick layers of dust on curtain rails around patients' beds’, revealing that a routine thorough cleaning practice was not in place.

Worse still, evidence of 'poor decontamination procedures' were reported, with 'soiled commodes, marked clean and ready for use', and 'a thick layer of dust ... on a blood culture bottle trolley outside an isolation ward’. Patients themselves expressed concern about the hospital's cleanliness, directing the inspectors to bloodstains on a bed rail and blood splashes on a wall behind a bed.

Examples of such poor practice are still distressingly common, but the case of Bromley Hospitals NHS Trust is revealing. Ian Wilson, the trusts Chief Executive, has only been in his post since mid-December 2007, and perhaps cannot be blamed for the Healthcare Commissions recent findings. His appointment brings to an end though, nearly 9 months of ‘interim’, externally sourced, Chief Executives, something which might well be responsible for the obvious lack of good management at the trust.

Moreover, Mr Wilson’s predecsssor, Mr Anthony Sumara, continued to work as NHS London's Turnaround Director while interim Chief Executive of NHS Bromley. One can assume that his hands on management time in Bromley was limited at best; and as he was selected specifically to cut costs, it is very conceivable that budget areas such as 'cleaning' saw a tightning in recent months.

One cannot criticise the NHS for trying to increase its economic efficiency. However one can criticize the way the NHS appears to be going about trying to achieve it. Creating a group of 'management executives' to parachute into ill-performing (in a financial sense) NHS Trusts, only to then be whisked away again after only a matter of months, will not improve the quality of care offered to patients. Real accountability and stability among NHS Trusts senior management just might. Of course perhaps the best way to improve healthcare in the UK is to learn some lessons from other European countries, and take it out of the government's hands altogether.      

The Healthcare Commission reports on NHS Trust failure

The Healthcare Commission have today released a study (PDF) summarising some of the lessons they've learned from studying failing NHS Trusts.  There are three broad themes that should be of interest to anyone trying to learn policy lessons from the study:

1)  Management weaknesses

"We have found that the boards of NHS trusts we have investigated are particularly vulnerable to being consumed by the business of healthcare, in the form of mergers, reconfiguration of services, financial deficits, and targets.

[...]

Continuity of leadership is important, too. We have found recurring cases of poor leadership in the trusts we have investigated, with frequent changes in senior personnel and a lack of strategic direction, serious financial or capacity concerns and failure to deal with historical problems. In one case, there had been seven chief executives in 10 years, as well as four different trusts under three different health authorities – all creating a lack of continuity and follow-up of management action."

This lack of continuity isn't just a problem for NHS Trusts but also affects the very top of the NHS organisation.  Our report Wasting Lives: A statistical analysis of NHS performance since 1981 (PDF, pg. 31) revealed that there were twelve secretaries of state in the 23 years studied by the report.

Inexperienced and transient managers are distracted by procedural issues - such as mergers and financial deficits - and do not have the expertise and settled organisation that can ensure that these distractions do not harm standards of care.  If an organisation is unstable at the Chief Executive or Secretary of State level then the entire structure will suffer as more junior staff will have to work within the preoccupations of the higher-ups.

2)  How they understand the world

The Healthcare Commission sees the target culture and the poor use of outcome data as two separate problems.  They are actually two sides of the same issue.

NHS organisations are not controlled by the market, and the threat of creative destruction, as they operate as an effective monopoly with a unique access to taxpayer funding.  Instead, they are held to account by simplistic targets.  What that means is that data on performance isn't seen, by NHS Trusts, as a tool to aid decision making - in order to better serve patients - but as a resented source of embarassment, giving politicians and other authorities a stick with which to beat them.  This mindset is encouraged by the way the NHS is organised and makes effective decision making close to impossible.

3)  Poor standards in everyday non-critical care

"Poor care of patients on general wards – the relatively small number of our investigations of acute hospitals has revealed worryingly similar stories of poor care for patients on general wards. Patients who were older or otherwise vulnerable were most at risk, since they were most dependent on good nursing care and not always able to express their needs.

We found examples of patients not being helped with eating or cutting up their food, tablets not being given on time and medication missed, charts not completed properly, and patients being moved from one location to another because of the pressure on beds."

This is again the result of the NHS being monopolistic.  Without the threat of patients leaving and no longer providing their custom there is every incentive for NHS Trusts to cut corners on the little details that make hospital stays bearable but don't show up on the Government targets.  While most doctors, nurses and other hospital staff will still treat patients well out of common decency an incentive to cut corners will lead to substantial numbers of patients not getting the care they should be able to expect.