Hard Choices
David Aaronovitch had an excellent article in the Times the other day in which he set out the case for clear and hard-headed decisions to be taken on a number of topical and controversial policy issues - energy, transport and deliver of NHS services.
To my mind the arguments in favour of greater specialisation in the NHS are overwhelming - which means that people can't expect to have a local hospital acting as a 'jack of all trades' capable of dealing with every ailment under the sun.
Likewise with transport where the big High Speed 2 project was set in train, so to speak, under the last Labour Government - yet is now coming under a sustained and partisan attack even though high speed trains are part of the 'furniture' these days in
European countries such as France and Spain.
Meanwhile UK energy prices which have been steadily increasing for years, again a process started by Labour to rebuild the industry's failing infrastructure while meeting climate change targets - is effectively being set aside as the Labour leadership suddenly decides that the market is failing and that a temporary price freeze is the solution.
Even though Ed Miliband as Labour's energy minister approved the reduction in the number of suppliers from 22 companies to what we have now, the Big Six - just as the National Audit Office announces that sustained investment, via price rises or some other means, will be required for the next 17 years.
We can’t leave A&E reform to our children
By David Aaronovitch
Flunking big decisions on the NHS, energy generation or transport is a fatal and expensive error
When I saw the headline that Bruce Keogh, the top man at NHS England, was proposing to divide A&E in two, my mental image was of a nurse directing accidents in one direction and emergencies in another. In fact what is being suggested is much more radical. Of the current 140 hospital A&E departments, about a third will become “major emergency centres” dealing with the most complex and traumatic cases, and two thirds will be “emergency centres” where less serious cases are treated.
Of course the language does remind one a little of the dismal categorisation of public schools in Evelyn Waugh’s Decline and Fall: “ ‘We class schools, you see, into four grades: Leading School, First-rate School, Good School, and School. Frankly,’ said Mr Levy, ‘School is pretty bad . . .’ ” But other than the language, the proposals make eminent sense. Some A&Es no longer offer a complete range of services in any case, and at quite a few of those that do, patients with difficult conditions attend at their own peril.
It has been obvious for years to health service planners and other experts that a process of concentration was required for specialist services, complemented by a much more comprehensive system of local health provision. Some of this has happened, with huge benefits for mortality rates. A lot hasn’t. Every time a facility is closed or downrated, it seems, a noisy campaign starts up to save it, but no campaigns ever seem to be launched to provide adequate local nursing or good walk-in clinics.
Although the problem of poor care and overcrowding at hospital A&Es was entirely predictable on demographics alone, it has been discussed by reference to the prejudices of the moment. It is the fault of lazy, overpaid GPs (I’m sure these exist, but I’ve yet to meet one), or of health tourism by an indeterminable number of migrants, or of the Government’s unnecessary reorganisation — delete according to taste.
Some things don’t have to be local. And I have put my belly where my mouth is on this. In January I needed a complicated and painful (although not life-threatening) operation, which has a 34 per cent failure rate. As this company provides insurance and I had enough money for the trip, I went to Edinburgh to have the operation done by one of two experts in this procedure working in the UK (the other is based in Devon). My GP and I worked on trying to achieve this through the NHS, but the system defeated us. So, for six days I was in a Scottish hospital, separated from my family by a five-hour train journey. I traded temporary isolation for the expertise of the surgeon and I’m glad that I did.
Yet if and when departments start being “downgraded” (as it will be put) and the new system of separating the serious from the not so serious begins, the row will be enormous. Perhaps it will be so enormous that the plan never gets off the ground. MPs who know such change is right for the country will discover that it’s somehow wrong for their town. We’ll find some way of applying a temporary bandage to the wound, and leave it for a future generation to deal with the inevitable gangrene.
As we have done with energy. The whole country knows that energy and other utility prices have gone up a lot. An average of 8.1 per cent this year, while increases in earnings have been a fraction of that. The nation believes they have gone up too much. To blame are (a) greedy, profiteering, (often foreign-owned) energy companies or (b) unaffordable levies designed to encourage green energy in the face of mythical or unavoidable climate change. Again, make your choice according to your prejudice.
There are 17 more years of this to come, according to the National Audit Office. Slap on a windfall tax! Freeze prices for a year! Get rid of the green levies! Get those prices down. For if we don’t get to the next whisky bar, I tell you we must die.
As the Audit Office makes clear, the biggest reason for energy price rises, apart from increases in wholesale costs, is the need to invest hundreds of billions in infrastructure that had been allowed to become old and inefficient. Our bills are not high compared with other nations, our green taxes are hardly crippling and the profits of energy companies are not unreasonable. Yet we let the system go to pot because, back in the day, no one wanted to decide whether to pay for new plant out of taxation or out of the pocket of the consumer.
Why don’t we have sufficient rail capacity? Yet the great campaign is on to oppose HS2, the long overdue attempt, among other things, to improve capacity. Why don’t we have sufficient airport capacity around London after 50 years of debating it? And yet the Noes have destroyed any hope of a third runway at Heathrow, and we are no nearer a resolution than our fathers and mothers were. Why have we left it so late to build new nuclear capacity, when we have known about our looming energy gap for decades? Nuclear power? Neine danke.
These are not the questions asked by a fascinating and zeitgeisty book published a few weeks ago. The Blunders of our Governments,by the veteran political analysts Ivor Crewe and Anthony King, is a catalogue of dreadful failures on the part of our rulers. It has some of the disasters you have heard of such as the poll tax, and some you may have lost sight of, such as Gordon Brown’s PPI arrangement for London Underground.
Crewe and King make a lively case for the sins of commission by a system that, unlike that in the US, allows a government with a majority to exercise unchecked power. They show what happens when government consults badly, deliberates without evidence and acts too quickly. And if they miss out many fine projects that were controversial at the time, but whose value has tuned out to be immense (Lord Heseltine gave the slightly self-serving example of the London Docklands recently). Well, “Our Brilliant Government” was never likely to sell as a book idea.
So I would like to invite Messrs King and Crewe to write the sequel to Blunders, which could be called “The Price of Inactivity”, or “The Path Untaken”. It would deal with the enormous costs — financial and human — incurred by not making decisions when they are best made. Some would be constitutional, such as proper reform of the Lords, Commons and voting systems, regional devolution (what a mistake the North East made in turning that down!) and party funding. Others would be in making necessary but unpopular adjustments to taxation, such as house and land revaluation. Yet more in the major structural projects such as housebuilding, energy and water delivery and health.
But that’s the problem. By the time people realise that your generation has flunked the big tests, you are probably long gone, leaving only some old photographs and a few crises behind you.
Flunking big decisions on the NHS, energy generation or transport is a fatal and expensive error
When I saw the headline that Bruce Keogh, the top man at NHS England, was proposing to divide A&E in two, my mental image was of a nurse directing accidents in one direction and emergencies in another. In fact what is being suggested is much more radical. Of the current 140 hospital A&E departments, about a third will become “major emergency centres” dealing with the most complex and traumatic cases, and two thirds will be “emergency centres” where less serious cases are treated.
Of course the language does remind one a little of the dismal categorisation of public schools in Evelyn Waugh’s Decline and Fall: “ ‘We class schools, you see, into four grades: Leading School, First-rate School, Good School, and School. Frankly,’ said Mr Levy, ‘School is pretty bad . . .’ ” But other than the language, the proposals make eminent sense. Some A&Es no longer offer a complete range of services in any case, and at quite a few of those that do, patients with difficult conditions attend at their own peril.
It has been obvious for years to health service planners and other experts that a process of concentration was required for specialist services, complemented by a much more comprehensive system of local health provision. Some of this has happened, with huge benefits for mortality rates. A lot hasn’t. Every time a facility is closed or downrated, it seems, a noisy campaign starts up to save it, but no campaigns ever seem to be launched to provide adequate local nursing or good walk-in clinics.
Although the problem of poor care and overcrowding at hospital A&Es was entirely predictable on demographics alone, it has been discussed by reference to the prejudices of the moment. It is the fault of lazy, overpaid GPs (I’m sure these exist, but I’ve yet to meet one), or of health tourism by an indeterminable number of migrants, or of the Government’s unnecessary reorganisation — delete according to taste.
Some things don’t have to be local. And I have put my belly where my mouth is on this. In January I needed a complicated and painful (although not life-threatening) operation, which has a 34 per cent failure rate. As this company provides insurance and I had enough money for the trip, I went to Edinburgh to have the operation done by one of two experts in this procedure working in the UK (the other is based in Devon). My GP and I worked on trying to achieve this through the NHS, but the system defeated us. So, for six days I was in a Scottish hospital, separated from my family by a five-hour train journey. I traded temporary isolation for the expertise of the surgeon and I’m glad that I did.
Yet if and when departments start being “downgraded” (as it will be put) and the new system of separating the serious from the not so serious begins, the row will be enormous. Perhaps it will be so enormous that the plan never gets off the ground. MPs who know such change is right for the country will discover that it’s somehow wrong for their town. We’ll find some way of applying a temporary bandage to the wound, and leave it for a future generation to deal with the inevitable gangrene.
As we have done with energy. The whole country knows that energy and other utility prices have gone up a lot. An average of 8.1 per cent this year, while increases in earnings have been a fraction of that. The nation believes they have gone up too much. To blame are (a) greedy, profiteering, (often foreign-owned) energy companies or (b) unaffordable levies designed to encourage green energy in the face of mythical or unavoidable climate change. Again, make your choice according to your prejudice.
There are 17 more years of this to come, according to the National Audit Office. Slap on a windfall tax! Freeze prices for a year! Get rid of the green levies! Get those prices down. For if we don’t get to the next whisky bar, I tell you we must die.
As the Audit Office makes clear, the biggest reason for energy price rises, apart from increases in wholesale costs, is the need to invest hundreds of billions in infrastructure that had been allowed to become old and inefficient. Our bills are not high compared with other nations, our green taxes are hardly crippling and the profits of energy companies are not unreasonable. Yet we let the system go to pot because, back in the day, no one wanted to decide whether to pay for new plant out of taxation or out of the pocket of the consumer.
Why don’t we have sufficient rail capacity? Yet the great campaign is on to oppose HS2, the long overdue attempt, among other things, to improve capacity. Why don’t we have sufficient airport capacity around London after 50 years of debating it? And yet the Noes have destroyed any hope of a third runway at Heathrow, and we are no nearer a resolution than our fathers and mothers were. Why have we left it so late to build new nuclear capacity, when we have known about our looming energy gap for decades? Nuclear power? Neine danke.
These are not the questions asked by a fascinating and zeitgeisty book published a few weeks ago. The Blunders of our Governments,by the veteran political analysts Ivor Crewe and Anthony King, is a catalogue of dreadful failures on the part of our rulers. It has some of the disasters you have heard of such as the poll tax, and some you may have lost sight of, such as Gordon Brown’s PPI arrangement for London Underground.
Crewe and King make a lively case for the sins of commission by a system that, unlike that in the US, allows a government with a majority to exercise unchecked power. They show what happens when government consults badly, deliberates without evidence and acts too quickly. And if they miss out many fine projects that were controversial at the time, but whose value has tuned out to be immense (Lord Heseltine gave the slightly self-serving example of the London Docklands recently). Well, “Our Brilliant Government” was never likely to sell as a book idea.
So I would like to invite Messrs King and Crewe to write the sequel to Blunders, which could be called “The Price of Inactivity”, or “The Path Untaken”. It would deal with the enormous costs — financial and human — incurred by not making decisions when they are best made. Some would be constitutional, such as proper reform of the Lords, Commons and voting systems, regional devolution (what a mistake the North East made in turning that down!) and party funding. Others would be in making necessary but unpopular adjustments to taxation, such as house and land revaluation. Yet more in the major structural projects such as housebuilding, energy and water delivery and health.
But that’s the problem. By the time people realise that your generation has flunked the big tests, you are probably long gone, leaving only some old photographs and a few crises behind you.
