The UK’s response to coronavirus has been marked by incompetence.

It’s a difficult situation for any government to manage, but the problems  produced by coronavirus have been marked by muddle and incompetence in the response from the government.  I think we can exonerate them of three serious charges.  It was not inappropriate to delay the initial response: they judged, that people would not comply with instructions until they were convinced of the seriousness of the situation, and so it proved.  It was not obviously wrong, before the numbers became apparent, to ask whether the disease could be allowed to run its course with with only moderate social distancing.  (An illuminating set of simulations, published online by the Washington Post,  suggests that this strategy would still have been more effective than quarantines.)  And it is not wrong to impose restrictions that cannot be adequately enforced.  The nature of the disease’s spread is that every reduction in social activity limits the potential of the disease to spread.  It cannot be stopped, but it can be delayed, and delay makes it more possible for services to cope and ultimately to the availability of a vaccine.

Having said that, there have been several marked problems in the government’s response to the situation. The problems include:

    • Preparation
      • The lack of testing means that the government has not been able to keep track of what is happening, let alone manage public health issues such as contact tracing.
      • The failure to provide personal protective equipment for medical staff is utterly disgraceful.  Hospitals have become a danger zone.
    • Protection
      • The government’s first response was to protect business; its second response was to protect employees.  There are still major problems evident in the protection of people in precarious employment and those on benefits.  I have covered those issues separately.
    • Process
      • Contradictory and inconsistent advice.  There have been frequent, repeated, muddled statements from different government ministers and advisers about what is required, what the rules are, and who is affected.  Instructions are imprecise.  For example, there is still prevarication about what is essential work, such as whether or not construction can proceed.  And if the aim is self-contained households with minimal interaction, what is wrong with individuals working alone on an allotment?
      • Announcements have been sudden and immediate, making it difficult for people to close business or even to move physically to the right location for isolation.
      • Over-reaction.  The police have criticised the public for going to isolated places to walk and exercise.  I am in the middle of a house move – my furniture left on the van on Friday – but the registration of  property transactions has stopped,  and the Law Society has advised solicitors not to conclude business.  I don’t claim any medical expertise, but I think I can say with confidence that coronavirus cannot leap down the circuitry of internet communications to emerge at the other end and eat you.

Additional comment, 28th March:  The Lancet has published a blistering editorial condemning the incompetent preparations for the pandemic. 

February should have been used to expand coronavirus testing capacity, ensure the distribution of WHO-approved PPE, and establish training programmes and guidelines to protect NHS staff. They didn’t take any of those actions. The result has been chaos and panic across the NHS. Patients will die unnecessarily. NHS staff will die unnecessarily. It is, indeed, as one health worker wrote last week, “a national scandal”. The gravity of that scandal has yet to be understood.

Covid-19: a few questions about the government advice

I was asked once to examine a sick sheep.  What I know about the diseases of sheep and other animals wouldn’t cover the head of a pin, but I manfully walked up to the sheep in question.  It promptly got up and ran away.  I was able at least to call back, “It’s alive”.  It’s always nice to find oneself in a position to make definitive pronouncements, and it seems to me that many of the statements coming from government have at least as much authority as I did with the sheep.

The strategy of the UK government is to normalise the illness, as we have done with other killers such as influenza: allow for large numbers of healthy adults to be infected, reserve special defences for people who are particularly vulnerable, and accept that some people will die.

This position is out of step with the WHO advice, which is to contain the illness.  It is not indefensible, but there are a few holes to fill in the policy.

Question 1:  How will we know if the government’s strategy is working?  If there is no routine testing, we cannot say much if anything about numbers – and so, we will find it difficult to say whether or not the policy is working.

Question 2: What is the cost of telling people not to seek help?  The recommendation to self-isolate and soldier on through the course of the disease depends heavily on people contacting services in due course when problems become serious.  That involves more than self-isolation: it depends on self-assessment.  How many people will this kill?

Question 3:  What happens to people who can’t self-isolate?  The advice that is being given asks people to isolate themselves within their home, to keep a distance and not to make contact with others.  That is feasible for about two-thirds of the UK population.   The others don’t necessarily have a space they can isolate themselves in.  Some have no home; some share their bedrooms with others.  And we might point out that the UK government has issued various edicts requiring poorer people to share rooms.  It is the policy of the UK government not to permit people on benefit to be supported if they have spare rooms, and to penalise them financially  if they do.

Question 4: What happens to people on benefits?  As things currently stand,  there are severe penalties for non-compliance with benefit regulations, including the requirement to seek work, to attend meetings and appointments, and to be available.  Benefit claimants have limited room for manoeuvre – there are limits on how many periods of sickness and how long a person can be excused.

Question 5.  Where, in a society in lockdown, will people’s income come from?  In the short term, the problems identified in questions 3 and 4 could be dealt with in part by two immediate measures:  stop the bedroom tax, and stop all sanctions.  There is a more severe underlying problem, however: our economy and our labour market do not deliver regular, stable incomes for many people.   Under the old system of Unemployment Benefit, people reduced to short-term working or interruption of earnings would receive direct help, based not on a personalised means test but a simple question, about whether or not they had worked on that day (any day where someone had earned £2 was deemed to be a day at work).  We no longer have that system.  Successive governments have undermined the principle of social protection.  We need it more than ever.

Harry Burns on mortality figures

I’ve recently joined the board of Barony Housing Association, which is part of the Wheatley Group, and consequently was invited to a institutional lecture by Prof Sir Harry Burns, who was considering mortality statistics in Scotland and the UK.  He made the case that, despite the emphasis on nutrition in much of what’s written about public health, nutrition is not at the core of the problems.  Scotland’s nutrition-related mortality follows a pattern, astonishingly, which is not much different from Finland’s.  Finland has an exemplary nutritional policy and lots of virtuous practices, and Scotland (notoriously) doesn’t.

The real difference in mortality, he argued, occurs in younger age groups; and the primary issues for the mortality of younger adults are drugs, alcohol, violence and suicide.  All of which are social.

The reform of social care will take more than money

The House of Lords Economic Affairs committee has called for free personal care in England, on lines similar to the system in Scotland.  “Under free personal care individuals would therefore only receive funding for support with these basic activities of daily living, based on the minimum threshold of eligible needs as defined by the Care Act.” They are recommending a major increase in the funding for social care, so that care can be delivered on much the same terms as health care.  However, they accept that people should pay accommodation costs themselves, with means-tested support, and they recognise that this might entail “catastrophic accommodation costs” which might have to be subject to a cap.

This has been welcomed as a radical proposal, but it doesn’t touch on most of the problems that go with social care.  We’re still thinking of social care as a set of needs which can be satisfied by specific cash payments.  The Lords report explains:

“Personal care means essential help with basic activities of daily living, such as washing and bathing, dressing, continence, mobility and help with eating and drinking. It does not include other areas where support might be needed, such as assistance with housework, laundry or shopping.”

I don’t believe that a system based on this approach can ever deliver what people want to see.  I don’t believe people want, or are comfortable with, successive 15 minute visits from a team of people who bathe them, or dress them, or help them to bed.  I don’t believe that what most people really want in life is to manage a rota.  I don’t think that providing for a series of events, sold as if they were commodities, meets people’s human needs.  What we should be allocating is time with a person, and that calls for a different approach to assessing needs from one that focuses on whether or not someone needs help with brushing their teeth.

What’s wrong with the idea of opening the NHS to US traders? Plenty.

There’s been a lot of discussion about the potential for a trade agreement with the USA and its possible impact on the NHS.  “I think everything with a trade deal is on the table,” Donald Trump has said.  “When you’re dealing in trade everything is on the tabl,e so NHS or anything else, a lot more than that, but everything will be on the table, absolutely.” The response of those who want there to be such an agreement has been to say that it won’t matter – a “storm in a teacup”, one IEA spokesperson commented. US firms are already providing services in UK health care.  Services can be provided by a range of providers; what matters for the consumer is that the NHS continues to offer services that are free at the point of delivery.

This view may be disingenuous, because there is a strong financial incentive not to see the problems.  It is certainly mistaken.  The usual complaints from the left are that profit-making firms are extractive, and that competition consumes resources.  Either might be true, but the problems run much deeper than that.  There is now abundant evidence of what happens to public services when ‘competition’ or part-privatisation is introduced.  I have just had a paper rejected which makes the arguments in some detail – admittedly it’s too tendentious for an academic journal – but I can sketch out a couple of points here.

There is no system, anywhere, that is wholly public, any more than there is a system that is wholly private.  The NHS has had an uncomfortable relationship with the private sector, but its successful functioning relies mainly on two pillars: that the private sector is small and select, and that the services are sufficiently integrated to ensure that really serious cases can be taken over by the national service.  Both of those are at risk from creeping commercialisation.

The fundamental problem in any mixed system is that commercial providers get to choose what they cover; public providers, committed to meeting the needs of a population, do not.  Commercial providers select those areas of operation which they are undertaking to provide – that is how markets work.  That means that in general they will select those activities which deliver the best return per unit.   It follows that some things will be left out; when they are, the public services will have to deal with them as provider of last resort.  (Take a simple illustration, delivering post and parcels.  If private firms can subcontract for the profitable bits, they choose the easy runs – between major cities, or within busy areas.  In the case of private health care, that has generally meant a preference for relatively low-risk elective surgery, while long term psychiatric or geriatric care don’t attract the insurers or the services.)

Taking those points together, that must also mean that public services have a higher cost per unit than the private services – the difference is built into the process.    Politically, there are constant complaints that public services don’t work as well as private ones.  Of course they don’t; they have to take on the bits that private providers leave behind.

That’s the unavoidable part of the problem.  Some other things follow in the wake of that structure.  They may be avoidable, but they are still difficult.

  • There is a continuing incentive for private providers to cut corners – skimping on service, paying less, holding to the letter of complex contracts.
  • The public sector has to develop processes for sub-contracting and compliance, which are expensive and uncertainly effective.
  • When private providers get it wrong, and services collapse, the public services have to pick up the pieces.

There’s obviously a lot more to be said about competitive structures, but that’s why I started out trying to write a paper on it rather than a blog entry.

Making people work for their health care

The Economist this week carries an article and an editorial piece about what they are calling “The Arkansas experiment“.  In January 2018 President Trump announced that there would be federal waivers to allow states to introduce a test of ‘community engagement’ for entitlement to Medicaid.  Medicaid is the means-tested system offering support in the US for health care for people of working age; ‘community engagement’ means, more or less, a work test, requiring people to be working, ‘volunteering’, studying or responsible.  Arkansas is so far the only state to implement this, but the Economist notes that 14 other states have applied for similar waivers.

The Economist expresses some doubt about the policy: it is complicated, engagement is difficult to prove in a world of precarious work, and incentivisation is perverse.  The main thing that sick people need before they can work is to be healthy.  But they start with a rather questionable statement of principle:  “The theory behind tying cash benefits to work requirements is sound. Asking people to do something in exchange offer a payment can build political support for welfare programmes”.    Conditionality may well be the price that politicians have to offer to get a programme accepted; that’s not the same as saying that conditionality leads to greater support.  If anything, the polities where people are most determined to impose conditions on the poor are also usually the ones where support is most tenuous.

The “theory” behind work requirements, if it deserves to be called a theory,  is highly questionable.  ‘Activation’ policies, which are supposed to prod unemployed people into work, are based on a series of false premises – that benefits used to  promote unemployment ‘passively’, that the answer to unemployment is more vigorous job-seeking, and that people will not move into work without a spur.  Empirically, activation doesn’t improve job matching; there is some evidence that it can make lead to mismatches, or even slow down the rate at which people move in to employment.  ‘Activation’ for people who are sick – a policy we’re now seeing in the UK, reflected in the treatment of sick people on ESA and Universal Credit – is worse still.  People on these benefits have to ready themselves for work nevertheless – sickness is no excuse.  It’s only a small step from there to the extension of the same principle to health care.  Depression?  Ulcerative colitis?  Congestive heart failure?  Pull yourself together!

 

 

The NHS long-term plan for England is not really a ‘plan’

I’ve not been close to work with the NHS for some years, and I’ve been away from England rather longer; but I think I know what a plan looks like, and the NHS Long Term Plan isn’t it.  The supposed plan is a long, rambling shopping list, lacking in structure, priorities or the means of achieving any aspirations people might have.  It’s all very well to say that the service will “dissolve the divide between primary and community health services”, or that people will have “more personalised health care when they need it”, but we need to know why, how, and how we will know if it’s happened.

One of the implications of the lack of structure is that there will be no way to tell whether or not this document has made any difference.  Being told, in bold lettering,  that “The health  service will continue to support implementation and delivery of the government’s new five-year action plan on Antimicrobial Resistance” or that “every trust in England with a maternity and neonatal service will be part of the National Maternal and Neonatal Health Safety Collaborative” tells us nothing at all – and if those objectives aren’t achieved, the gaps will be covered up by the rubble from hundreds of other equivalent objectives which might be achieved on the whole, or in part, or not at all.    The problem with long lists of policies,  Aaron Wildavsky wrote in Speaking truth to power,  is that they become a way of burying the things that don’t get achieved – “mechanisms for avoiding rather than making choices”.  The NHS Long Term Plan doesn’t identify problems, aims, methods, process, outcomes, or how to get value for money.  That doesn’t inspire confidence for the future.

Is the NHS the best health care service?

An international ranking of health services in 11 countries rates the UK NHS at the top.  The Commonwealth Fund, an American think-tank, ranks health systems on five main criteria:  Access, Equity, the Care Process, Administrative Efficiency and Health Outcomes.  Each of those criteria is based in turn  on a range of subordinate indicators:  the “Care Process”, for example, takes into account prevention, safe care, coordination, and patient engagement.  It’s backed up further by more detailed assessment;  for example, the US does badly on infant mortality and premature death, but relatively well in relation to doctor-patient relationships and the management of stroke.  But speaking as a carer, I find it hard to believe that the state of our mental health services really represents the best that anyone can do.

The main purpose of the report is to give a critical perspective on health care in the US, which is outstandingly expensive as well as being the least effective of the systems; but there are questions to raise about other countries, too.  For the UK, we might wonder how it is that the health care system is ranked top of the league while the UK’s health outcomes are the second worst in the table.   The neo-liberal Institute of Economic Affairs commented, acerbically: “the NHS’s provision of care is equally poor for everybody, irrespective of income.”

 

The crisis in the NHS

Leaving aside the question of whether the NHS has a ‘humanitarian crisis‘, which sounds apocalyptic, there’s much about the current state of the NHS which is based in long-standing problems.  The first problem is the lack of spare capacity in the hospitals. The effect of insisting that beds have to be fully occupied is to create inflexibility and bottlenecks.

However, the problems which show themselves in the hospitals are not necessarily problems which can be addressed through the hospitals.  The second key issue has been the retrenchment of social care.  Social Services Departments, or Adult Care Departments, have radically reduced the scope of their involvement with the public: figures are difficult to find, but between 2008 and 2013 the numbers of people being served fell by a quarter.

The third problem has been an apparent failure of GP coverage.  This is puzzling because the figures seem to imply the opposite.  Currently there are 5.8 GPs per 1000 patients per practice.  That   averages out to just over 1700 people per GP, in the worst cases rising above 2300.  When I started in this game the ratio of GPs to patients used to be 2200, in some areas going up to 3500, and that was in the days when GPs also had to come out at night.  However, there appear to be more people on GP lists overall than there are in the population – suggesting that general practices and CCGs are not very good at keeping their records up to date, possibly because it’s not in their interests to do so.  I’ve also not been able to find respectable figures for how many people are not registered with any local GP, which may be marginal (the same people are less likely to get access to any health care) but is potentially important in the demand for direct access to A and E.

It’s understandable that the government is focusing on GPs, because it’s the most immediate response that could affect the numbers of people coming into A and E without directly requiring new capital investment to do it.   Demanding that GPs change their office hours, however, is not likely to make much difference; this redistributes the times when people get seen, but it’s no guarantee that more will be seen and where, for example, a GP is taken off a Monday rota to go on a Sunday rota, it may mean (depending on the practice setting) that fewer are.  There may be other implications.  GPs do much more than talk to patients; they also coordinate continuing care and the multidisciplinary team.  (I understand this may be different in England, where GPs have been complaining that they’re more remote from community nursing.)  If at least one GP has always to be seeing patients, when can the practice ever have team meetings to discuss care management?

The fourth problem concerns how we respond to the population in need.  We should dismiss one of the common explanations: that the ageing population itself implies a greater burden.  There are theories about the ‘expansion of morbidity’, suggesting that people are ill for longer; there’s a contradictory view, the ‘compression of morbidity’, which says that people are healthier for longer – but frankly the evidence isn’t convincing for either of them. (The issues are discussed in a WHO report, Global health and ageing.)  However, it is true that local population movement does increase local demands in some places – the South East of England is overcrowded while some areas of Scotland are depopulated.  That’s  a different kind of issue.  We need to give more thought to the kind of services that are available for a mobile and often transient population.

Rationing isn’t best done by charging for services

A discussion on the Radical Statistics list sent me off looking through some old material.  The cash crisis in the National Health Service has fuelled calls for charges to be introduced, as a way of quelling demand. Charges, however, are not a good way of doing this.

This table was part of a paper I never published – I cannibalised sections for a book, and put the arguments differently.

Normative criteria applied to different forms of rationing

 

Distributive equity Access for a target population: avoiding errors of exclusion Reducing aggregate demand Selectivity:
avoiding errors of inclusion
Procedural
fairness
Denial of service – closing the doors ?
Rationing by price ?
Filtering/ referral processes ? ?
Eligibility criteria
Priority weighting ? ? ?
Dilution – less service for everyone ? ? ? ?
Deterrence ? ?
Delay – waiting times ? ?

 

Some of the ratings might be questioned – I think, for example, that there is a case to show that making people wait has bad distributive consequences, not just questionable ones.  The central point to take from this is that there is no reason to suppose that price rationing has any intrinsic superiority over other methods. If anything, it is rather inadequate as an instrument of public policy: it has nothing to prevent inappropriate inclusion or exclusion, and while some people think it’s a fair procedure (which is debatable), it is unlikely to be fair in distribution. Waiting lists and queues are not much better. The two methods of rationing which relate best to most of the criteria are eligibility rules and filtering, such as triage or using referral processes.