Political Economy

According to the BBC http://bbc.in/bARDUv the local government expenditure is to be cut in Scotland by 5.6%. Since the Scottish government received only a 4.16% cut in the money given to it by Westminster this seems rather hard on the people of Scotland.

But do not forget that English authorities have already had to make cuts in the last fiscal year, cuts that the Scots were allowed to defer to this year. So the local government cuts this year are actually the total of two years’ cuts.

Mark you had Westminster also started to remove the £4.5 billion subsidy to Scotland that comes from English taxpayers at a rate of £1.1 billion a year the Scottish government would have faced a cut of 7.9% this year. Had this resulted in a pro-rata cut in Scottish local government expenditure of £0.4 billion it would have resulted in a 9.8% cut. A cut that covers two years

Odly enough this is still less than the 9.9% average cut in the central government grant to English local authorities for one year. http://bit.ly/dGmUUK

So when you are told in England that your services have been cut just remember that overall they have not been cut and that the Scots are spending your money on their comfort!

So says the National Museum of Afghanistan. If you go and visit the current exhibition at the British Museum you will get some idea of how ancient this culture is http://bit.ly/fzBANs.

The Taliban famously tried to destroy the culture by destroying its artifacts and inflicting their strict version of Islam on the country. Whilst much was destroyed the curators of the museum secreted the objects away that are now on display. They were only able to bring them back on display in 2003 once NATO had driven the Taliban out.

Afghanistan has had numerous groups come and go over the millennia.  Some of the golden artifacts on display were over 4000 years old and belonged to a bronze age civilization with what appear to be links to Mesopotamia.

The Greeks arrived under Alexander the Great and built the great city now known as Ai Khanum. This city was lost in antiquity and was replaced by a local civilisation, then by Persia, India, the Mongols and so on.

But however courageous are the curators of museums the Afghan culture or for that matter the English culture will not stay alive unless it stays alive in the hearts and actions of the people.

The Labour plan to crush English culture by allowing wave after wave of mass immigration to swamp our schools, to change the way of life of the people of England, to denigrate the very name “England” will not be ended by the wholly inadequate measures of the coalition government.

The policies of the English Democrats will do this. Having a devolved parliament and government of England, with fiscal devolution on devolved matters, will allow the English culture to be protected and promoted just as the Scottish culture is in Scotland and the Welsh culture is in Wales.

A referendum to leave the EU and the end to all mass immigration will allow immigration on the basis of fitness for the job and for a limited period only when no local people can do the work.

The removal of all illegal immigrants and a strict application of the convention on asylum which requires refugees to settle in the nearest safe country to their own will reduce the excessive demand being placed on hospitals, schools and housing.

Giving local people priority in housing will not only return natural justice to the social housing market, it will make England a less desirable place to emmigrate to.

Putting an end to multiculuralism and expecting everyone in their public life to respect and follow English values and ways of doing things, including speaking English for all residents, will protect and expand English culture.

Putting an end to political correctness will mean that the large amounts of money spent, and wasted, in this area can be directed towards the less well-off young and elderly.

The suspension of the European Human Rights act and its replacement by a sensible English variation will allow the deportation of immigrants and asylum seekers, who commit crimes, to their country of origin. In a number of cases this will cause those intent on criminality to think twice about their actions.

Policies like these are often branded as racist by knee-jerk anti-English groups. But actually not one of these policies is based on racial or ethnic criteria. English Democrat policies are based on a cultural identity. Englishness resides in the heart and so can be adopted by any person of good will.

If you want to preserve the culture of England as a living thing, as a matter of the heart, rather than an artifact in a museum, the Conservative party will not do this, the Labour party will not do this,  the Liberal-Democrats will not do this nor will UKIP, not the Greens and certainly not the BNP.

Only the English Democrats are wholly committed to the fundamental proposition that “A Nation stays Alive when its Culture stays Alive”. Vote English Democrats on the 5th May.

In the recent coalition spat Cameron and Clegg have shown totally different views to privilege – even though both of them appear to have benefited equally from privilege in the past.

Apparently great advantage accrues to young men and women who gain an unpaid ‘internship’ in a bank, law firm, company and so on. Cameron is more than happy if these privileged positions are kept in a tight circle of friends whilst  Clegg wants them distributed in a more open fashion.

This desire to preserve privilege to the few is merely a public showing of a private wish to preserve wealth and power based only on the basis of private gain and not on the basis of public gain. In other words Cameron, the Big Society is only for the those idiotic plebs who have swallowed your  deceits and not for you and your friends. This gut reaction of Cameron says more about him, as we will see, than anything else he has said for political consumption.

Clegg on the other hand appears to have an understanding of economics and is honest enough to admit that doing good for the country might involve the giving up of a bit of privilege by the wealthy.

The bit of economics I refer to is the fact that if we want to grow in wealth as a nation we will have to use the talents of all the people and not just of those whose accident of birth has put them in a privileged position which they had no part in creating. If we want to grow as a country we will not do this by limiting access to the knowledge and networks of power to those who already have them. If we want to grow economically as a nation we will have to grow more open as a society with more opportunity for more people.

There is support for the view that Clegg is correct in the Financial Times of the 23rd April – St George’s Day. An article by Daniel Pimlot listed the economic benefits and costs of the Royal wedding. The cost included the reduction in national output of a bank holiday. This is apparently £2.9 billion. For some reason or other the article also included the estimate, made last year, by the Boston Consulting Group that concluded that if we had the same social mobility  as the Finns our national output would be higher by £56 billion! Or, to put it in words that Cameron and his privileged friends can understand, 19 additional bank holidays per year!

To put it in the language that the rest of us ignorant plebs understand the tax take on £56 billion would be around £20 billion which coincidentally is the same as the cost savings being taken out of the NHS by Cameron.

If you ever believed Cameron when he said he would ensure the NHS was safe in his hands the natural outcome of his gut reaction to the small reduction in the privilege of the wealth being proposed by his coalition partner should surely convince you otherwise.

In the past years there has been much research around the world into what creates high quality health care. A seminal event in this field was the publication in 2006 of “Redefining Health Care: Creating Value-Based Competition on Results”, by Michael Porter and Elisabeth Teisberg (http://www.hbs.edu/rhc/).

Whilst being, to a large degree, US centric this book’s core message is applicable to any health system in the world. Indeed, as Porter makes clear, every piece of their recommendations are being used successfully somewhere in the world but in a piecemeal fashion.

The book has put together the work that has been done in the last decades on quality, worldwide, with the tools Porter created for analysing strategy. The outcome is a health system that is surprisingly different from what we are used to today but which is implementable, when there is a will to change for the better. So what is it?

What is value in health care

In business terms value is simply the quality, as perceived by the purchaser, of the service purchased divided by the cost of the service. In health care

Value =     Health Outcomes (or Results)/Cost of the whole cycle of care

The outcomes measured depend on the medical condition and are adjust for the difficulty or complexity they present.

The cost is the cost over the whole cycle of care which has number of stages which, with some possible quality indicators for each stage, is shown below:

1    Monitoring/Preventing – Prevention of illness, early detection
2    Diagnosing – Correct diagnosis
3    Preparing – Early & right treatment for the patient,
4    Intervening – less invasive treatment, fewer complications, mistakes & repeats
5    Recovery/Rehab – Faster & more complete recovery, less care induced illness
6    Monitoring/Managing – slower disease progression, less need for long-term care.

Measuring across the whole cycle is important because choosing the wrong intervention, let’s say the cheapest one, may well increase costs in recovery or rehab or long-term management of the condition with frequent return to A & E to sort things out. These costs may be much higher than the cost saving at the intervention stage. Porter reports that in Taiwan, for example, they have reduced the time (and hence the cost) of a GP visit to 3 minutes, which is just enough time write a prescription. As a result the cost of drugs has ballooned and so have the number of GP visits, to an average of 20 per year per person!

Measuring outcomes is not an issue. Recording cost is not an issue. But doing both across the whole cycle of care, for one patient, for one incident of care is very much the issue as it will require the IT systems to do so – and we all know what happens to government backed IT systems.

How should we organise to deliver exceptional health value?

It will come as no surprise to some in industry that this will only happen when there are specialist units that treat a sufficient number of patients a day to acquire the experience and expertise to improve what they do.
Take the example of severe headaches. Those who get them will know how disabling the are. In West Germany they decided to set up a specialist unit with, in one place, the neurologists, psychologists, and physical therapists all of whom were passionate and deeply interested in curing severe headaches. This unit set up affiliations with an imaging unit, an in-patient hospital unit and with additional neurologists that were all similarly passionate about curing severe headaches.

To begin with costs went up as the centre was established but are now 25% lower for the whole cycle of treatment than they were before the change. This is not because the cheapest treatments or the cheapest imaging services or the cheapest consulting neurologist are used. It is because there are fewer hospitalisations and fewer returns to the specialist centres. The quality of health outcomes has increased whilst the cost of providing them has decreased, because of the increase in quality and not because someone has gone on a cost cutting spree.

Primary Care

The organisation of primary care will also have to change. Sixty years ago when fewer conditions were recognised, fewer effective treatments available and when half of us were dead before we were 70 it was possible to think of the heroic GP who could treat each and every medical condition presented to him/her. That is no longer true. That means that either GP practices will have to develop specialist units within them, and become very big so that consequently there will be fewer of them, or  each practice will have to specialise. This means that we might easily have to go to several GP practices over the course of a few years and not just one, as at present. GPs will be paid according to the quality of their part in the cycle of care, not cording to the number of patients on their list.

So why is Lansley Irrelevant?

Well to begin with he has fallen straight into the trap of believing that value for money is increased by reducing costs. He has gone for the £20 billion reduction in expense without realising that increasing quality of outcomes is the only sure way of reducing cost and the only way of doing this is to measure quality and cost over the whole cycle of care.

Secondly he is irrelevant because fiddling around with who commissions health care will have no effect on quality of health care unless the whole structure of the English NHS is changed to a structure that is designed to, and focused only on, improving quality. The cost reductions will come about because high quality means, in the language of industry, less rework, fewer warranty claims and totally satisfied customers.

Thirdly he is irrelevant because he is pinning his faith on GPs who themselves are going to have to make major changes in order for this higher quality health care to come about.

Fourthly he is irrelevant because, as Porter has noted, health professionals love working in these new structures once they realise that they are now enabled to work at the limits of their ability doing what they went into health care for in the first place – making people well!

Fifthly he is irrelevant because he is planning on bringing in private organisations, ostensibly to improve quality, but in reality to reduce cost based on an old and outdated view of how to produce high quality health care.

Finally he is irrelevant because he has spent 12 months wasting his time, and that of his civil servants, in putting together a 500 page Bill to do something that is not going to give the result wanted instead of seizing the opportunity he was presented with to make a truly significant increase in the quality of health care in England.

The lesson for Lansley, and the coalition government is, in the words of the quality guru Phil Crosby: “QUALITY IS FREE” (http://en.wikipedia.org/wiki/Philip_B._Crosby)

The Financial Times reported today that 35% of City professionals were dissatisfied by the size of their bonus!

Apparently some 79% of them got a bonus this year, paid out of a bonus pool of £7 billion which was much the same as the previous year.

Things look good in all directions in the City with job opportunities up by 6,426, the highest since August 2008 whilst the average salary of those who found new jobs in March was £54,445. Overall 89% had salaries that were higher or the same as last year.

This dissatisfaction with bonuses is despite the fact that earnings in the City rose by 5.4% in the three months to February. This is more than twice the level of everyone else whose pay rose, on average, by 2.2%.

Some 79% of City professionals earned a bonus this year; 38% got more, 43% about the same and 19% got less. The fact that some 35% of them appear to be unhappy with their lot begs the question about why we should be happy with them. There are many words that rhyme with “banker”, some are rude but many would say that they describe the City professional perfectly.

This month the Royal Free hospital in Hampstead said it would loose 450 jobs, many of them clinical in order to save £40 million. At this rate the £7 billion of bonuses is equivalent to over 78,000 jobs in the NHS.

Recently a senior City regulator said that he could discern little that was socially worthwhile in what the City did. Was he correct? What do you think?

For democracy to be seen to done in an election the candidate chosen must get more than 50% of the vote. If this does not happen you get the situation that we in the UK are familiar with. Candidates and governments are elected with less, sometimes much less than half of the votes cast. To get around this the French use the “run-off” system in their Presidential elections. In this, if the leading candidate does not have more than 50% of the vote, the candidate with the least number of votes is eliminated and the voters are called back to vote again. This continues until one candidate gets more than half the votes. Such a system ensures that a minority President, or government, cannot be elected. It is democratic and it is fair. But, with its multiple rounds of voting, it is arduous and time consuming.

The Alternative Vote system is nothing more nor less than a run-off voting system where you have to make you choices in how you would vote in subsequent voting rounds at the time you cast your first vote. It gives all the advantages of run-off voting such as fairness and democratic governments whilst avoiding the time and arduousness of the original version. (For more on the technicalities see the Note at the end of this blog.)

The already low standards of the “NO” to the Alternative Vote (AV) Referendum continue to drop.

Listening to BBC radio 4 on Saturday (19/3/2011) it transpires that a reason to vote “No” is that the AV will give someone who votes for the British Nationalist Party (BNP) a second vote. Notice that the speaker did not say that a reason to vote “No” was that it gave a Labour (or a Conservative, or a Liberal Democrat) voter a second vote! I do not like the BNP, but then I do not like the Conservatives, Labour or the Liberal Democrats either. However I do not make my dislike a reason to deprive a fellow citizen of their democratic voting rights.

The implication is clear. If you vote BNP, a legally registered political party, then you are not worth giving an alternate choice to. How fascist can you get?

I have said it before. The “No” campaign have used lies, deceit, anti-democratic and now fascist arguments to support their views.

A vote for the “No” campaign is a vote for a continuation of the status quo in our already creaking democracy. The speaker for the “Yes” campaign pointed out that the high point in the two-party system in England was in the 1951 election and that this was also the high point for the “first past the post” voting system. Now in a pluralistic political era we, the voter, desperately need a voting system that reflects the political realities and allows us the flexibility to vote in a way that reflects these multiple choices whilst giving us only candidates, and government, who have a majority of the votes.

Those who believe that the way to democracy is to cut voting costs should remember that this is what dictators believe. The fact that the “No” campaign believes this is no accident.

In reality what is not to like about the Alternative Vote system, the efficient, fair and democratic replacement for the run-off voting system?

Note for Readers.

Some voting systems require the voters to vote again if no candidate has more than 50% of the vote. At subsequent voting the bottom candidate of the previous round is eliminated.

The Alternative Vote System is an example of “Instant Run-off Voting. You have the choice to rank candidates – 1, 2, 3 and so on. When the votes are counted the candidate with most votes, provided this is more than 50% of the votes cast,  is elected. If no candidate has more than 50% then the candidate with the least number of votes is eliminated and their votes are given to their second choice. ALL the votes are now counted again and if no one has more than half the votes the new ‘last’ candidate is eliminated. This continues until a candidate has a majority. See Wikipedia