The richest 1,000 people have more wealth than the poorest 40% of households (UK)

The richest 1,000 people in the UK have more wealth than the poorest 40% of UK households. The 1,000 richest saw their wealth increase by a staggering £82.5 billion last year, the equivalent of £226 million a day, or £2,615 a second.

The Equality Trust has found that this increase in wealth of £82.5 billion could:

Pay the energy bills of all 25.6 million UK households for two and a half years. Cost = £79.15 billion OR

Provide 5,143,819 million Living Wage jobs , or 2,923,333 million jobs paid at an average salary for a year. Cost = £82.476 billion OR

Pay the grocery bill for all of the UK’s users of food banks for 56 years . Cost = £81.5 billion OR

Pay two years’ rent for 4.5 million households (4,528,000 households) . Cost = £72.1 billion OR

Pay for 68% of the budget for the NHS in England Cost = £81.6 billion
Pay for 4 years of adult social care in England . Cost = £78.8 billion.

This totally unearned bonanza needs justifying somehow. It arises merely from the structure of wealth ownership, tax laws, and property holdings. The beneficiaries had to do little beyond what they currently own or do to enjoy this largesse.

One justification for the support of the current social structure of wealth ownership and control is that these people pay in absolute terms a good deal of tax. If you are destitute at least you don’t pay tax. Consider however that if one paid tax on income on say, £1,000,000, under current tax rates you would still get £540,676 per year. You pay nearly 44% of your income.

The median in the U.K. in 2017 is £27,000. Thus you take home £21, 641. You pay 20% of your income. You take home 4% of what the high earner does.

The millionaire pays as much tax in one year (£458,000) as a the median earner would (£5,200 pa) in 88 years. This is of course ‘inequality’.

So for every 1 person receiving £1,000,000, you’d need 88 on the median. Impossible of course due to what median means. The top 1000 get, receive, not ‘earn’, considerably more than what to them what would be a miserable £1,000,000 pa.

Those who earn up to the £150,000 threshold of 40% take home £90,176. Each extra pound they then get is taxed at 45%. What if that tax rate was 90%? This would mean someone getting £200,000 would receive £90,176 up to the £150,000 threshold and then another £5,000 taking it to £95,176. Someone getting £1,000,000 would after tax get £90,176 + £98,500 = £188,676.

The price of a loaf of bread would be the same.

So even at 90% marginal tax rates over the threshold, a millionaire would not have to worry about paying utility bills. Yes they pay more tax, but what’s left for them is hardly destitution. I digress. Millionaires to the 0.01% are paupers. Billionaires can avoid paying any taxes at all.

A second justification is that they are the ‘wealth creators’ and so deserve it all. I will not unpick this here because the rebuff is as obvious as the claim is spurious.

A third justification is that changing this structure would lead to economic chaos and left wing totalitarianism. This sets up a false dichotomy of either keeping hold of wealth or descent into tyranny.

A fourth justification is that the wealthy need to get ‘rewarded’ as they operate in a competing market, and that pay rates merely reflects market forces at work? Well, indeed but should that really be a plea to hold on to vast amounts of wealth? Are you really saying that you are miffed because someone else gets £5,000,000 pa while you get a ‘paltry’ £2,000,000 ?

There is a fifth technical justification – the Laffer Curve:

“In economics, the Laffer curve is a representation of the relationship between rates of taxation and the resulting levels of government revenue. Proponents of the Laffer curve claim that it illustrates the concept of taxable income elasticity—i.e., taxable income will change in response to changes in the rate of taxation.

The Laffer curve postulates that no tax revenue will be raised at the extreme tax rates of 0% and 100% and that there must be at least one rate which maximizes government taxation revenue. The Laffer curve is typically represented as a graph which starts at 0% tax with zero revenue, rises to a maximum rate of revenue at an intermediate rate of taxation, and then falls again to zero revenue at a 100% tax rate. The shape of the curve is uncertain and disputed.

One implication of the Laffer curve is that increasing tax rates beyond a certain point will be counter-productive for raising further tax revenue. A hypothetical Laffer curve for any given economy can only be estimated and such estimates are controversial. The New Palgrave Dictionary of Economics reports that estimates of revenue-maximizing tax rates have varied widely, with a mid-range of around 70%. Generally, economists have found little support for the claim that tax cuts from current rates increase tax revenues or that most taxes are on the side of the Laffer curve where additional cuts could increase government revenue.

Although economist Arthur Laffer does not claim to have invented the Laffer curve concept, it was popularized in the United States with policymakers following an afternoon meeting with Ford Administration officials Dick Cheney and Donald Rumsfeld in 1974 in which he reportedly sketched the curve on a napkin to illustrate his argument.”

See: Laffer Curve

If all else fails, fall back on classic economic models which are of course nothing more than mathematical representations of actual human behaviour in particular social and political contexts. They do not operate like the laws of physics. Hence they can easily change given different contexts.

With these vacuous and self serving justifications, the 1% keep the status quo going. Every society needs a unifying myth, and the powerful 1% need one even more so. Monarchy, Nation State, and ‘Free Market’ Capitalism (note: not financial/rentier/crony capitalism) are used as unifying myths to merely cover wealth and privilege. It is why right wing politics intuitively support monarchy, church and the flag because if those are dismissed by critics then that only leaves the theory of free market neoliberal capitalism as a defence against ‘the underclass’.

You decide if this level of wealth appropriation is good for social cohesion and health inequalities.

Health and Social Care – the Tory Legacy

Health and Social Care – the Tory Legacy:

 

David Cameron appeared in jovial mood both in the commons and on the steps of number 10 when he recently left office. Cameron joked at his last prime minister’s questions in the House:

other than one meeting this afternoon with Her Majesty the Queen, my diary for the rest of the day is remarkably light“.

He listed his achievements in office and seemed not to be too bothered to be leaving.

It is not clear whether people, especially frail older people, will be so sanguine about his record.

When it comes to health and social care, ‘the nasty party’s’ record is appalling. Following largely on the heels of the Health and Social Care Act 2012 and Osborne’s deficit reduction targets for the public sector, and in the face of increasing demand, we have what Roy Lilley (2013) predicted, and called, ‘The big blue bit of doom’:

His diagram was prescient, as two reports below indicate. This is having an effect on staffing levels and thus on the quality of care people get.

 Jim Mackay, CEO of NHS Improvement, recently was reported in the Health Service Journal (July 2016):

“…Trusts exceeding the 1:8 nurse to patient ratio could be told “we can’t afford that”.  

Trusts, he suggested, should not automatically spend money on new staff or better facilities on the basis of a CQC report or in an attempt to meet Royal College standards.

Janet Davies CE of the RCN stated in reply

This gives completely the wrong message to trusts, whose boards are responsible for the care, treatment and safety of their patients, by suggesting that finances are more important than patient care”.

 I’m afraid in the current context that major decision makers do think finances are more important than the quality of patient care.

 

The King’s Fund (2016) reports:

 

  1. NHS providers and commissioners ended 2015/16 with a deficit of £1.85 billion – the largest aggregate deficit in NHS history
  2. The scale of the deficit signifies a system buckling under the strain of huge financial and operational pressures.
  3. The principal cause of the deficit is that funding has not kept pace with the increasing demand for services

 

The 2016 ADASS (Directors of Adult Social Services) budget survey report states:

 

  1. Funding doesn’t match increased needs for, and costs of, care for older and disabled people.
  2. More people’s lives are affected by reductions in social care funding. The quality of care is compromised: 82% of Directors report that more providers already face quality challenges as a result of the savings being made.
  3. Directors are increasingly unclear where the funding needed will come from.
  4. The continuity of the care market is under threat. Providers are increasingly selling up, closing homes or handing back the contract for the care they deliver to older or disabled people.
  5. Investment in prevention is being further squeezed.
  6. Reduction in funding for social care has wider impact. Directors feel that negative consequences due to budget cuts have already been felt right across health and social care and agreed particularly strongly with statements regarding issue faced by the wider sector:
  • 85% thought that the NHS is under increased pressure
  • 84% thought providers are facing financial difficulty
  • 85% thought providers face quality challenges

 

NICE produced the original safe staffing guidance, centred on the idea that 1:8 was acceptable, provided somebody could wave a ‘red-flag’ and additional staff summoned. The guidance was based on the work of Anne Marie Rafferty et-al, who never said 1:8 was safe, it will not be.

Roger Watson (editor of Journal of Advanced Nursing), wrote for The Conversation UK on a recent study:  https://theconversation.com/youre-more-likely-to-survive-hospital-if-your-nurse-has-a-degree-61838 and thus provides more evidence of the strong correlation between education and outcomes. My worry is that in the UK we have drifted into ‘policy’ based evidence rather than EBP. Safe staffing levels may well be decided by finance directors (what can we afford) rather than sound evidence. This reminds me of the climate change ‘debate’ of which Roger Pielke applies the ‘iron law of economics’:

When policies on emissions reductions collide with policies focused on economic growth, economic growth will win out every time. Climate policies should flow with the current of public opinion rather than against it, and efforts to sell the public on policies that will create short-term economic discomfort cannot succeed if that discomfort is perceived to be too great. Calls for asceticism and sacrifice are a nonstarter.”

So ‘when policies on nurse staffing collide with policies focused on deficit reduction, deficit reduction will win out every time. Staffing policies will flow with the current of finance directors/CEOs opinion, and efforts to sell them policies that may cost them cannot succeed if that cost is perceived to be too great’.

A question is that while there is a perception that degree nurses and lower nurse patient ratios will increase the wage bill, while not providing savings ‘on the bottom line’ then we have a political battle not an evidence battle. The externalities of FDs and CEOs decisions fall onto individuals, families and nurses rather than the organisations balance sheet. Do we have metrics that force the financial externalities back into the equation, or is there evidence that hospitals see this evidence and are changing staffing practice?

The Tory Legacy is that we are still chasing a target of deficit reduction within a wider ideology that is suspicious of public sector provision at best. The drift is towards more private provision with perhaps a base line that the tax payer pays and a system of tops ups and private insurance schemes. This will be sold as “we cannot afford the NHS as it is” to cover for much further privatisation, marketization and a return to individualising, rather than socialising, risk. Health and Social Care as we knew it is over. If you or your parents need caring for in older age, or if you need non urgent surgery, you will need to save more money to pay for it, take out private insurances, top up your pensions or pay more tax.

Crises in health and social care. Who pays/who cares?

Crises in health and social care. Who pays/who cares?

 

Roy Lilley has recently blogged about the provision of social care for older people in the UK. The important point being made is that private providers, Saga in this case, are finding that they cannot make any money out of providing that service. If they cannot make any money then the business is worthless. The question then is who will take this on?

 

Marion Dakers, financial services editor for the Telegraph, reported (in January 2015) that Saga was selling its publically funded care home business. In 2011, Saga took-over Allied Healthcare. This is important because Allied claimed that 93% of local authorities contract with them.

 

The CEO of Saga, Lance Batchelor, said:

 

“…the margins were not enough to justify the investment needed to grow the business…

 

In May 2015, David Brindle reported:

 

“… the Saga group quietly slipped out preliminary annual results recording a loss of £220m on its ‘discontinued’ Allied Healthcare business, largely through writing down its balance-sheet value to nil.”

 

There was more:

 

“… this value has been determined by considering the current asset and liability position of the business; the future profit cash flows and the associated capital investment set out within the management’s five-year plan for the business; the risk attaching to the various cash flows and the costs of disposing of the business,”

 

Brindle also commented that:

 

“In so far as homecare featured in the (2015) general election campaign, it was in respect of the sector’s questionable labour practices: heavy reliance on zero-hours contracts and low, occasionally illegally low, pay. We heard little or nothing about the centrality of the sector to any hope of making our health and social care system sustainable”.

 

Saga said:

 

There are a range of ways of valuing the business and it is our expectation that an appropriate buyer will ultimately value the business higher than nil.”

 

So currently Saga’s homecare business is worth nothing, in a market worth £6 billion. They hope however that a future buyer will be able to value the business above zero. What confidence do we have that a private sector provider will want to enter this business without increased payments from the local authorities who buy the service, or without decreased costs coming from cutting provision, downward pressure on pay or selling off assets.

 

The wider context is that local authorities have faced budget cuts under the last government and therefore they have less money to pay for social care.  A possible way of meeting the shortfall between what the LA pays and the actual cost of provision could come from individuals or families, or private insurance schemes. Efficiency savings in providing care seem unlikely to reduce costs.  Will a private sector company want this business without government financial support? Brindle’s point remains: to what degree is the current system of health and social care financially sustainable?

 

Roy Lilly argues:

 

“Considering the margins and liabilities involved; loss of reputation and brand value if something goes wrong, bad publicity or a serious, sustained quality failure… this is a toxic business. No one in their right mind will touch it. The business is worth nothing”.

 

If this turns out to be the case, who is going to pay for the health and social care needed by an increasing number of older people in the community?

 

Margaret Thatcher once said:

 

there is no such thing as society, only individuals and families”

 

One way of reading this is to think that society will not and cannot provide care, because it does not exist, and so it is up to individuals and families to do so. This is rooted in Edmund Burke’s philosophical conservatism which is distrustful of a big state. It is also rooted in Hayekian free market economics that also sees little or no role for the state in many spheres of social life beyond providing a safety net. ‘Individual responsibility’ for health and social care is a lightning rod, it channels fears about big state socialism which is antithetical to conservative, and neoliberal thinking. The answer is of course for more private insurance schemes if individuals and families want to provide care. The main message being sent out by government since 2010 is that ‘the money has run out’. The implication is that now individuals and families will have to pay more for health and social care because the state cannot.

 

David Cameron, in a speech at the Lord Mayor of London’s Banquet on November 11th 2013, outlined the strategic objective: ‘austerity is here to stay’, he said:

 

“The biggest threat to the cost of living in this country is if our budget deficit and debts get out of control again…we have a plan…it means building a leaner, more efficient state. We have to do more with less”.

 

Efficiency savings will only get us so far. Part of the ‘more’ he refers to is ‘more social care for older people’ with ‘less’ meaning Local Authority spending cuts. Again, how will this be paid for?

 

A 2012 report by the Nuffield Trust and the Institute for Fiscal studies on ‘NHS and social care funding: the outlook for 2021/22’, suggested:

“…only a long term freeze in other public service budgets or large tax rises could enable a return to the 4.0% average annual growth to which the NHS has become accustomed”.

Health and social care are currently split in terms of funding, but care needs, be they social or health, are in reality are part of the same package. The NHS needs increases just to stand still. So we are facing further freezes in public service provision, this may include LA payments for older people in social care and care homes, as large tax rises were not promised by the Tory government in the 2015 election.

 

The recommendations of the Dilnot Commission on Funding care and Support called for major reforms that would, if accepted, increase costs to the taxpayer. So both Dilnot and Nuffield suggest tax increase might be needed. This is antithetical to Cameron’s ‘more with less’ and to the visceral loathing felt by many on the political right for taxes. Cameron and Osborne are not stupid men, they must have been briefed in detail on this issue.  One conclusion is that during elections and in public they talk ‘tax cuts’ but in private know they will have to raise taxes or face down those requiring health and social care?

 

Richard Humphries, at the King’s Fund, gave a stark warning to people in the UK regarding paying for social care:

“I think they can expect very little unless they are very poor or have very high needs, in which case they will get help both with arranging care and with paying for it. But for the majority of people they will be expected to pay for it themselves.”

 

The BBC has set up a ‘costs of care calculator’ – a first step perhaps in understanding in future liabilities for care costs.

And for balance – don’t expect the leadership of the Labour Party to be any more generous on this issue.

Has anything changed? The malefactors of great wealth.

I came across a quote in Oreskes and Conway’s (2014) ‘The Collapse of Western Civilization’ from a speech made by a national leader. At this point, I will not name or date the speechmaker. I thought it interesting as a view on the relationship between a nation state and its wealthy individuals and thus on the nature of democracy. What follows are parts of the speech with some commentary in bold. I think it speaks to us today.

 

“National sovereignty is to be upheld in so far as it means the sovereignty of the people used for the real and ultimate good of the people; and state’s rights are to be upheld in so far as they mean the people’s rights. Especially is this true in dealing with the relations of the people as a whole to the great corporations which are the distinguishing feature of modern business conditions”.

The democratic deficit in both the USA and in Europe is that increasingly voters’ rights are being increasingly limited and bound by the rights of corporations and through the actions of corporate lobbying and political influence. The Transatlantic Trade and Investment Partnership  (TTIP) further threatens nation state and citizen democracy by allowing corporations to sue governments if they implement social and environmental protection legislation that the corporation deems a barrier to trade. Thus, national sovereignty is being eroded by such new legislation that does not recognise the sovereignty of people. Globalised capital flows are also eroding national sovereignty through capital mobility and a lack of a globalised governance in such issues as tax evasion and climate protection.

“Experience has shown that it is necessary to exercise a far more efficient control than at present over the business use of those vast fortunes, chiefly corporate, which are used in interstate business”.

More efficient control is now seen as anti-business and anti-democratic by the corporate class executive and the political power elites within a neoliberal idiocy that wants smaller and smaller state interference.

“But there is a growing determination that no man shall amass a great fortune by special privilege, by chicanery and wrong doing, so far that it is in the power of legislation to prevent; and that a fortune, however amassed shall not have a business use that is antisocial”.

This determination has been somewhat diluted as exemplified in Peter Mandelson’s famous quote that new labour is “Intensely relaxed about people getting filthy rich” and Boris Johnson’s eulogy to the rich as an ‘oppressed minority’. In addition we have Tax laws favouring the 1% and their offshore havens and finance capital that rewards fancy financial products while being socially useless. They argue as an article of faith that if taxes on the rich go up, job creation go down to justify their snouts in trough. Nick Hanauer debunks this idea in this short Ted talk. The rich are not job creators.

“Almost every big business is in engaged in interstate commerce and…must not be allowed…to escape thereby all responsibility either to state or to nation”.

Globalisation. If you don’t like our employment practices and wage structures then we will take our investments elsewhere; we will take advantage of the weakness of global labour and call it flexibility. You should be grateful you even have a job.

“The…people became firmly convinced of the need of control over these great aggregations of capital, especially where they had a monopolistic tendency…”

The people have become blind and disorganised, many have been persuaded to vote against their class interests. Many wish there was greater control, but are unsure of how to do it.

“There is unfortunately a certain number of our fellow countrymen who seem to accept the view that unless a man can be proved guilty of some particular crime he shall be counted a good citizen no matter how infamous a life he has led, no matter how pernicious his doctrines or his practices”.

CEO’s of certain banks, some hedge fund managers, asset strippers, CEO’s in the fossil fuel lobby and industry, climate change deniers…..many who form part of the corporate class executive who view corporate social responsibility either as marketing ploy and as a façade to mask their antisocial and anti-environmental business practices. Their rewards are knighthoods, huge salaries and bonuses, because their activities are legal and increase shareholder value.

“There is a world-wide financial disturbance, it is felt in Paris and Berlin…on the New York stock exchange the disturbance has been particularly severe…it may well be the determination of the government…to punish certain malefactors of great wealth…”

They are conspicuous by their absence in criminal courts and yet no common thief has ever cost the country so much.

“….who shall rule this country – the people through their governmental agents or a few ruthless and domineering men, whose wealth makes them particularly formidable, because they hide behind breastworks of corporate  organisation”.

We know the answer now. Government agents are discredited, lobbied or have become representatives of capital, not the people.

“I…hope that the legislation that deals with the regulation of corporations engaged in interstate business will also deal with the rights and interest of the wageworkers…it will be highly disastrous if we permit ourselves to be misled by the pleas of those who see in an unrestricted individualism the all sufficient panacea for social evils…”

Hayek, Friedman, Reagan, Thatcher, Bush, Blair, Cameron. The high priests of neoliberal individualism who first philosophised and then preside and encourage low wage, part time, zero hours economies and call this ‘labour flexibility’.

“The rich man who with hard arrogance declines to consider the rights and the needs of those who are less well off, and the poor man who excites or indulges in envy and hatred of those who are better off, are alien to the spirit of our national life. There exists no more sordid and unlovely type of social development than a plutocracy for there is a peculiar unwholesomeness on a social and governmental idea where wealth by and of itself is held up as the greatest good. The materialism of such a view finds its expression in the life of a man who accumulates a vast fortune in ways that are repugnant to every instinct of generosity and fair dealing or whether it finds expression in the vapidly useless and self-indulgent life of the inheritor of that fortune…”

We now have demonization of the working class, poverty porn on our TVs and victim blaming focusing on immigrants, welfare claimants and benefit cheats as a way of deflecting public anger on the state of public finances and the accumulation of wealth in fewer and fewer hands. The 1% now blame the poor for their fecklessness and lack of hard work resulting in the poor man increasingly turning to such ‘tools’ as jihadist ideology in reprisals. Meanwhile the middle classes in the UK bleat on about inheritance tax that is set at such a level that most of them will not pay it in any case. Turkeys voting for Christmas, Lemmings searching for cliffs, donkeys asking for whips.

 

This speech was given by President Roosevelt 1907  – the words in bold are mine. There is nothing new under the sun, the same issues regarding wealth and its influence and practices exercised Roosevelt over a hundred years ago. Between then and now various policies and legislation were put in place to deal with those worries. However, we have now reverted back to a time when we can again speak of the ‘Malefactors of Great Wealth’. This time around Obama is aware of inequality as a ‘defining challenge of our time’ but is wary of raising it for fear of being accused of class warfare. Roosevelt had no qualms about calling these people out for what they are.

The NHS in ruins: Small state private medical care is the future?

You would have to have been living on a desert island, celebrity obsessed or just plain ‘not interested’ to know there is an issue with NHS funding. The issue at stake is not that there is a funding gap between demand and provision, although that is certainly the case. The issue is the dismantling of the NHS as a publically funded service based on core principles. These principles are based on progressive, socialist/collectivist values rooted in social democracy. In short, the larger political project currently underway is the shrinking of the state by transferring its core functions of empowerment and protection of the public, to private, often global, corporations. The ‘moral mission’ of government is being eroded in favour of profit and individualising risk and responsibility.

 

Before we briefly examine this claim, it might be a good idea to remind ourselves of the current basis for the NHS:

 

The NHS was a political project founded in 1948 on the following guiding principles to address inequalities in access to medical services. The 3 core principles were:

1. that it meets everyone’s needs.

2. free at the point of delivery.

3. based on clinical need, not the ability to pay.

Since then these 3 have been developed into 7 principles underpinning the NHS constitution.

1. The NHS provides a comprehensive service available to all.

2. Access to NHS services is based on clinical need, not an individual’s ability to pay.

3. The NHS aspires to the highest standards of excellence and professionalism.

4. The NHS aspires to put patients at the heart of everything it does.

5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.

6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.

7. The NHS is accountable to the public, communities and patients that it serves.

NHS Core principles

 

These principles derive from a social democratic root, instigated initially by the post war labour government under the guidance of Aneurin Bevan , Minister for Health in the Attlee government of 1945 to 1951 at a time when the UK owed far more as a % of GDP than it does now. Despite this national debt, the Attlee government still found the money to set up the NHS. So from the outset, this was a political project based on collectivist principles and for this reason is now seen by free market conservatives, neoliberals and small state conservatives, as undesirable. However, as the NHS has huge public support, these critics of collectivism use the language of ‘affordability in austere times’ to frame the debate rather than outright argue for the wholesale privateering of the NHS and a move to individual responsibility for health based on health insurance. As part of this process, there appears an almost deliberate softening up of the public for this privateering and abdication of government responsibility for the protection of the public’s health and medical services. As a result of government policy we are being exposed to stories about NHS funding such as:

The Royal College of General Practitioners asks patients to petition the government on the issue of funding cuts”. This was reported by Neil Roberts in May 2014, who writes that a poster showing queues outside a GP surgery, and a claim that up to 100 practices face closure, is being sent to GP practices. Roberts states:

“The poster and petition, which the college is asking patients to sign, are part of the Put Patients First: Back General Practice campaign, run with the National Association for Patient Participation. The campaign calls for an increase in general practice’s share of NHS funding to 11% by 2017”.

Is this a case of special pleading? I don’t think so, the health service is facing a funding issue, including the £20 billion Nicholson challenge. In the context of rising demand, and an increasing gap in the budget to meet that demand, the NHS requires some radical changes or faces a ‘productivity challenge too far’ (Appleby, J. (2013) A productivity challenge too far? BMJ 344 e2416). One report from the parliamentary Public Accounts Committee, suggested that 1 in 5  NHS Trusts were in financial trouble and bankruptcy was a real option, this despite the NHS having an overall surplus of £2.1 billion in 2012-13. This surplus may not last, and the seemingly disorganised, costly management and inspection schemes alongside the disintegration of the providers into an ‘any willing provider’ mix of public and private do not bode well for the financial future of the service. The Private Finance Initiative (PFI) schemes have also locked some NHS organisations into costly long term contractual agreements.

So, yes the NHS is facing many challenging issues that some argue require a solution not yet fully implemented, although started, by the Health and Social Care Act 2012. This solution is to reduce public provision and encourage private sector organizations to tender and compete for services, they would be known as ‘any willing provider’. In theory this means Tesco as well as small social enterprises.

To get to this position, the NHS has to be seen to be not working and the current pressure on reducing public spending assists this process. Lack of funding, allied to poor services, paves the way for further privateering. The argument is that the state cannot provide the funds and also should not provide the funds, but it is the former argument – ‘austerity’ that is being used as a shield for the latter.

David Cameron, in a speech at the Lord Mayor’s (of London) Banquet on November 11th 2013, outlined the strategic objective: ‘austerity is here to stay’, he said:

“The biggest threat to the cost of living in this country is if our budget deficit and debts get out of control again…we have a plan…it means building a leaner, more efficient state. We have to do more with less”.

Debt reduction as an imperative, masks the ideological position for a smaller state.

Let us not forget, for this government will have you do so, that the debt rose as a result of the bank bail out rather than out of control state spending. The successful narrative is that the debt is all Labour’s fault and that big state spending cannot go on. The global financial crash of 2007-8 is a very useful smokescreen hiding conservative wishes to reduce the state’s functions.

Health and medical services in this worldview is not a public good, it is a commodity to be bought and sold in the market. If the NHS can be seen to be failing, to be expensive, then you have a narrative which states that the answer is selling off the services to private companies and introducing competition. So, why not privatise the NHS?

We already have a model for this; it is childcare, the costs for which is seen primarily as the responsibility of the individual and the family, with just a little state support. The private sector is paying so little for so many families with children, and private sector landlords have private rents so high, that the state is subsidizing low pay with benefits. The idea that the whole of society benefits from well educated, healthy children, and thus has an interest in supporting their development, is sidelined when it comes to paying for that care. Childcare costs are largely picked up by individuals and families. The state supports families with tax credits, child allowance and is introducing some measure of support for childcare for parents who are working. This support derives from a collectivist, not an individualist, political philosophy, and as yet has not been fully withdrawn. This is partly meeting the government’s moral mission to empower and protect its citizens. Conservatives argue however that benefits should be cut, and wonder why those who choose to have children are not fully paying for them, after all it was their choice!

We do not know how far Cameron wants to push competition and more private provision for medical services, we don’t yet know how much of the more expensive US health insurance system he wants to copy. We do know that corporate lobbying for state contracts from companies such as Serco, Capita and GE occur for the more profitable services. See this short film on NHS lobbying .

The Free University argues:

The UK government is proposing to privatise yet more public services including Ministry of Defence procurement and the Fire Services. Other institutions such as the Met Office are also being considered for sale. Privatisation of NHS services has been underway for some time and will accelerate under the secret US/EU Free Trade Agreement currently in negotiation. These are all a manifestation of “Liberalisation“.

Linda Kaucher in 2013 stated:

“Liberalisation means offering investment opportunities transnationally and since the 1980’s, successive UK governments have prioritised liberalisation in both private and public sectors. Private sector liberalisation has resulted in overseas ownership of most UK enterprise. Privatisations in the public sector have been simultaneously liberalised, so overseas investors are involved in the public sector sell-offs (e.g. water, rail), private contracting (e.g. waste collection, hospital cleaning) and PFI schemes. Right now, it is the NHS that is at stake, as it is divided up, privatised and liberalised – potentially forever: once overseas companies are involved, it is very difficult to reverse liberalisations, and, inherently, also the privatisations underpinning them. This is even more the case as liberalisations are committed to international trade agreements –  which is precisely the purpose of trade agreements.”.

The drift is towards more privateering of medical services. Will we get a better health service with improved outcomes? Lets not confuse health with medical services; health is largely socially and politically determined, so even if the NHS is fully publically owned, health outcomes are determined elsewhere (socio-economic status, ethnicity, gender….). The NHS is providing medical services to treat illness and disease and to manage chronic long term conditions. So, will private provision improve medical outcomes, will it improve services for dementia, mental health, elderly care?

Nurses for Reform.

A free market nurse think tank:

“NFR has long argued that the NHS is an essentially Stalinist, nationalised abhorrence and that Britain can do much better without its so called ‘principles’ ”. (2008).

 

Health care is part of the ‘moral mission’ of government (Lakoff 2008 ‘The Political Mind p141) to empower and protect citizens. Lakoff argues that other forms of protection, such as the Police and the Fire services, don’t require insurance and health security likewise should be a function of government. Conservatives do not believe this, they feel that you should have health care only if you are willing and able to pay for it. If you are not making enough money then you probably do not deserve it. For conservatives, health is a commodity that should come with a price in the market. The post war consensus between conservatives and socialists in the UK held back this belief. This is now breaking down and conservatives are emboldened and empowered not only to make this argument, but to enact it.

 

Lakoff poses a simple question…will the privateering of the NHS serve the overall moral mission of protection and empowerment, will protection and empowerment be best served or undermined?

 

Those who argue it will not undermine this moral mission are also set to make a very large profit out of it.

 

 

 

Nurse -patient ratios – what is the evidence?

Peter Griffiths of Southampton University wrote on the researchgate site:

“…..this is an area with a massive literature. The positive association (between more nurses and better patient outcomes) has been demonstrated against a range of quality and safety measures – primarily safety. Linda Aiken is not the only researcher in the area but possibly the best known. 

Try : Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45 (12), 1195-1204 1110.1097/MLR.1190b1013e3181468ca3181463.

…for a comprehensive if slightly dated overview of the safety literature.

Recent reports from the RN4CAST study show associations with other outcomes e.g.:

Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., Griffiths, P., 2013. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L., Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal 344.

Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Sermeus, W., 2013. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50 (2), 143-153.

…although limited as they are all self report.

The translation of this to specific ratios is difficult – largely for the reasons highlighted above and the evidence on that policy is less clear cut. Try

McHugh, M.D., Brooks Carthon, M., Sloane, D.M., Wu, E., Kelly, L., Aiken, L.H., 2012. Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California. Milbank Quarterly 90 (1), 160-186.

For a favourable gloss.

Some of the limitations are covered in:

Griffiths, P., 2009. RN+RN=better care? What do we know about the association between the number of nurses and patient outcomes? International Journal of Nursing Studies 46 (10), 1289-1290.

…one issue that is very germane for many health sectors is the absence of medical staffing from this literature. See

Griffiths, P., Jones, S., Bottle, A., 2013. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. International Journal of Nursing Studies 50 (2), 292.

 

I would add:

This question is rooted within a wider context – that of managerialist control of care environments (Traynor 1999, Lees 2013) in which efficiency, effectiveness and economy are to the fore. This approach can militate against the consideration of qualitative, non measurable, outcomes which make a real difference to patients’ experience (Tadd et al 2011, Dixon-Woods et al 2013, Hillman et al 2013). The reality is that many health and social care sectors, in the UK, are under such financial pressure and managerialist control,  that the quality of the care experience is squeezed. Given current narratives of austerity, female undervalued labour and ‘private = good public = bad’, UK society has accepted that for example long term care of older people, and mental health, have to fight their corner for government and personal funding. I suspect that funders (e.g. DoH and FTs) ignore evidence, in any case, of staff-patient ratios, viewing it as idealistic and costly. However, they will not frame it in this way – the response will be that ratios are a blunt tool and should not be set down in terms of basic minimums. While I think it is imperative that evidence comes forth on this topic, we might need to consider that the translational model of evidence to policy is flawed. In the context of climate science,  Pielke (2010) describes the actual relationship between public policy and scientific research as problematic; it is not a linear ‘evidence to policy’ model.  The translational model, or ‘knowledge translation’ (Kerr and Wood 2008), in which scientists come up with answers which are then put into practice by policy makers (Wynne 2010) is contextualised within political and ideological frameworks such as that of neoliberalism and its adjutant, managerialism.  Naively we may think that the job of scientists, and their allies, is to improve the process of knowledge translation so that policy makers, guided by clear evidence, can make the right decisions. Drugs policy research is another example of the failure of this model. In nursing, even if we had irrefutable evidence, there is no necessary link to this and health policy on nurse staffing. The UK’s NHS is a ‘highly politicized setting’ (Traynor 2013), staffing of wards is as much a political as an empirical question.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. 35 (6) pp 939-955
Kerr, T., and Wood, E. (2008) Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy. International Journal of Drug Policy 19 (3) pp 223-234
Lees, A., Meyer, E., and Rafferty, J. (2013) From Menzies Lyth to Munro: The problem of Manageralism. British Journal of Social Work. 43 (3) 542-558
Pielke, R. (2010) The Climate Fix. Basic Books. New York.
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor, M. (1999) Managerialism and Nursing: beyond profession and oppression. Routledge. London
Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Palgrave Macmillan.
Wynne, B. (2010) Strange Weather, Again. Climate Science as political art. Theory Culture and Society 27 (2-3): 289-305

Funding cuts to nurse education – austerity hits students

“Universities say nursing education has reached a “tipping point”, with proposed funding cuts putting the quality of courses and ultimately the quality of nursing care at risk”

The funding cuts and increase in student numbers may well have a detrimental affect on the learning experience. To address it we have to adopt new methods – some of which we need to do anyway – such as increasing use of web 2.0 technology for example ‘webinar’ presentations and discussions. Simulations are expensive and time consuming and allied to pressures on mentors, we have an overall picture of stress on the system. This will increase the call to take education back into the NHS, to see students as part of the workforce and not supernumerary, and the adoption of training rather than education. The wider context is the increasing control of nursing for managerial reasons within the contested economic policy of austerity. The country largely believes there is no money for education, health or welfare. In addition the policy is one of creating a market for those public goods based on the idea of a ‘consumer’ exercising rational choices. That is why the student pays fees so that through a market mechanism they will drive up quality by only buying education from quality providers. That is the theory. There is money – its just that it is in the hands of the few that gov’t dare not touch.

In a report, a Tale of Two Britains, Oxfam said the poorest 20% in the UK had wealth totalling £28.1bn – an average of £2,230 each. The latest rich list from Forbes magazine showed that the five top UK entries – the family of the Duke of Westminster, David and Simon Reuben, the Hinduja brothers, the Cadogan family, and Sports Direct retail boss Mike Ashley – between them had property, savings and other assets worth £28.2bn.

The UK study follows an Oxfam report earlier this year which found that the wealth of 85 global billionaires is equivalent to that of half the world’s population – or 3.5 billion people. The pope and Barack Obama have made tackling inequality a top priority for 2014, while the International Monetary Fund has warned that the growing divide between the haves and have-nots is leading to slower global growth.

This is the real issue – inequality politics resulting in an impoverished public sector. JK Galbraith way back in 1958 argued that a feature of advanced capitalism was that public (sector) squalor went alongside private affluence. Quite.

Food poverty in the UK

George Osborne will give his Autumn statement to the House of Commons this Thursday. He will be upbeat about ‘recovery’ and GDP growth. What he will ignore is the fact that the recovery is very patchy, based on rising house prices, a mini consumer spending spree in certain areas (e.g. London) and increasing consumer public debt within the context of a low wage, precarious job market. These are part of the UK’s social determinants of health. The ’causes of the causes’ of ill health.

Admissions for malnutrition, BMJ graph

Watch out for entreaties to those will little resources to learn to cook and spend their money more wisely – in other words, “if your child goes hungry, it is your fault”.  This is what I call the default ‘Daily Mail’ individualist analysis which only gets you so far.  Use your sociological imaginations to analyse what is going on – how do you link the personal trouble of going hungry and being admitted for malnutrition with the public issue of food poverty in the UK today? The graph published by the BMJ shows that in 2008 when the UK experienced the start of the financial collapse, bank bail outs and the beginning of austerity policies aimed at reducing welfare spending, there were a little over 3000 admissions for malnutrition. In 2012 that had risen to about 5,500 admissions.

If only one person was admitted due to malnutrition we should look to the character and situation of that person for a proper understanding and analysis of why. When admissions have increased to 5,500 we need to look to wider explanations that go beyond the individual. What structural transformations are occurring which provide a fuller understanding of people’s experiences?

Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals” (C Wright Mills 1959).

we are not there yet

The tents that multiply in the City of London to house the anti-neoliberal capitalism protesters – representative of the 99% – echo the tents that still house the dispossessed around the globe as their only means of shelter. The tents in both cases symbolise the crushing failure of neoliberal dogma. Ideology in economic pontifications by ultra conservative loons have infected the Conservative and Social Democratic parties of the UK and the US and they continue to splutter and froth in anger at anyone who dares to say “up with this we will not put!”. Look at the figures, it has been said enough times and the facts do not lie. The Rich are screwing us all and we having to pay for their third and fourth holiday homes. The question now is this: is there enough momentum building to throw the money bastards out of the temple?

Even the comfortable middle classes must wake up and realise that rampant injustice and inequality is tearing at the social fabric and is not in our long term interest. The system is bust and must be reformed before someone gets hurt. Oh, sorry, someone has already been hurt. Its just that we don’t see them because thankfully we don’t have to live near them.

How many small businesses must go bust because of lack of finance, how many more jobs have to be lost, how many more young people must fight against each other to get a job. How many more children will grow up in poverty locked out of an elitist education system where social mobility has ground to a halt. How many more times will we let smug ‘I’m alright jack’ bastards tell us to ‘get on our bike?’.

Dear ‘Sirrallan’, an economy cannot be based on turning 1 million 16-24 years olds into entrepreneurs, by definition this role is a minority role, what are the rest to do?

It is estimated that currently in the UK we have a 1/5th to 4/5ths divide in regard to a decent living standard. Those of us in the 4/5ths should not be smug, some of us are prey to the old divide and rule tactic, a reserve army of labour suits the capitalist class just fine. We need a new politics, not the old left v right,  state v free market argument of polarised opinion.

The Rich will not voluntarily give up their privilege. Capital will continue to need to grow at at an average of 3% and has to overcome barriers to achieve this. The trouble is that the current anglo-saxon and european technological and organisational forms, social relations, institutional and administrative arrangements, production and labour processes, mental conceptions of the world, reproductions of daily life and the relationship to nature result in a crisis of capitalism that may result in the destruction of the old rich world economies. Capital flees elsewhere (China, Russia, Brazil, South East Asia) for that 3% growth if it cannot overcome US, EU and UK barriers. The euphemism is ‘creative’ destruction of capital in order to make way for new forms to emerge which will allow that growth. The reality is impoverishment of labour, a euphemism for early death, health inequalities…the poverty of mind, body and soul.

We have enough examples in the 20th century to warn us what may result if the social fabric gets too far torn. So far, the cloth has been ripped, the tear may yet be repaired. We must act before it becomes too late.

1. Break up the banks, nationalise some if you have to, and copy the german regional model. Make the f**kers lend.

2. Enact the Robin Hood tax, call the f**ckers bluff.

3. Invest in tax collection measures with at least as much energy as one does for benefit fraud.

4. Cap wages for the top, for sake of argument lets cap it at say, £400 k pa.

5. Accept that we are not an imperial power, we do not need nuclear submarines. Spend the money elsewhere.

6. QE for infrastructure investments in green technologies and for training and education.

7. Consider the ‘citizen wage’ which is allied to a simplified benefits system.

8. Focus on the real risk…not GDP growth but climate change, the planet will not wait for us to put the economic system right.

9. For f**ks sake just think differently! Think outside of the terms of reference of capitalism.

10. There is no 10. The last one covers it.

11. Stop treating nature as capital, it is finite and has its own intrinsic value. It is also a vicious bastard which will rid itself of the virus of humanity if we don’t respect it.

12. Encourage a poetic, artistic imagination.

13. Don’t have any more children. Import them from countries that have enough (its called immigration) or emigrate to China or more selfishly and pleasantly to New Zealand (oh, sorry they don’t like immigrants either).

14. Some of these suggestions will of course not fix the current issues but we need to scan the horizon for new ground to stand on.

Poverty in Cornwall

The Bishop of Truro is asking 9 supermarkets for boxes to be placed in their stores so that customers can donate food. This is supported by the county’s foodbank scheme.

According to Professor Townsend, poverty is defined as:

“Individuals, families and groups in the population can be said to be in poverty when they lack the resources to obtain the types of diet, participate in the activities, and have the living conditions and amenities which are customary, or are at least widely encouraged and approved, in the societies in which they belong”.

The government defines poverty as a family with two children living on less than £300 a week (BBC 2011). The Child Poverty Action group state that a measure of poverty is where household income is below 60 per cent of the median UK income after housing costs have been paid.

In June 2011 Cornwall council’s  Deprivation and Child Poverty report showed 19% (16,650) of under-16s living in poverty. Levels ranged from 2% in some areas to 58% on the Pengegon estate in Camborne.

Poverty therefore does not explain rioting, where are the street protests at this level of deprivation which equals that found elsewhere in the UK? This shows that simple cause-effect explanations for human behaviour are not adequate. Instead we must look to fuzzy analyses and solutions and come to understand that certain behaviours have different antecedents and require different tipping points. Poverty needs other variables which are not always measureable. Camborne as far as I know does not have a history of racial tension, police stop and search or gang culture. Neither does it have conspicious consumption and ostentatious privilege on show, the poorer areas do not sit cheek by jowl with Mansions. We would have to ask residents why they have not kicked up at this continuing level of disparity. Do they expect less? Have they internalised failure, are they ‘all in this together’?

Townsends definition perhaps illuminates. If poverty is experienced in relation to the ‘societies in which they belong’ then it may be posited that camborne society is sufficiently poor and cut off from privilege that residents do not feel excluded as they have little experience (apart from media projections) of social wealth? What protects camborne from looting? Poverty is certainly there but what is missing to turn this experience into social unrest?

Oh, by the way…donating food? In the UK ? Are we mad? What is it about society and people that we may think it necessary to donate food? Before you answer that, have you experienced living on 60% the median wage with two children for, say a year?