Welcome to National Health Serfdom

The 'S' in NHS, I understand, stands for 'service'. We seem to have forgotten this fact recently. It seems to mean serfdom.




During the height of our recent epidemic we were told to lockdown because the government feared that without such drastic actions the NHS would be overwhelmed. We can never know whether or not the decision to shut down 90% of society for six weeks was the reason why the NHS wasn't overwhelmed during the covid epidemic. But we (or most of us) acquiesced because it seemed the sensible thing to do given the dire warnings from expert epidemiologists.

The Tweet above, however, doesn't refer to a crisis situation but to the normal programme of vaccinating more vulnerable people against 'flu. This is a programme that takes place every winter and the reason we make the 'flu jab available is because we believe it protects those vulnerable people, and to a lesser degree, their neighbours from an infection that might kill them. People are not obliged to have a 'flu jab merely encouraged to do so. All-in-all this amounts to a pretty sensible public health programme, the sort of thing good health services might do. But the purpose of the vaccination programme has never been to "protect the NHS".

Here, in those three words, we have a repeated statement that you are servants of the system - you must do these things to protect the system not for your own interest. And as the ex-Tory MP who sent that Tweet responded, there are little heart strings to justify us serving the system - "...don’t (you) want to protect those midwives who helped deliver your grandchildren, or those GPs who will ensure you are kept healthy and well, or those care workers who change your families dressings...".

The slightly patronising tone here is part of the messaging, a sort of subtle authoritarianism, as is the conflation of people who work in the NHS with the service as a whole. How dare people refuse to comply with our instructions, how much damage are they doing to our precious NHS! This is the mindset that underlies so much of the fussbucketry in modern public health. You must stop smoking because it costs the NHS money. Cut out the booze because look at those admissions to hospital that might have a link to drinking. And don't you dare get fat, do you know how much money fat people drain from Our NHS!

Once you accept that interfering in lifestyle choices is justified by the (alleged) cost of those choices to the state-controlled health system, then you have moved from a person being served by the NHS to being a servant of that system. You were always a number on a list, a body on a slab, but now you're expected to change your behaviour to "protect the NHS". We will see a new collection of fussbucketries from public health all justified by the need to control the upward spiralling costs of our (not really very good) NHS. And all the while the good people who work in the NHS will be cast as special, almost saint-like - not because this is true but because by invoking their specialness, the message "don't get fat, think of the NHS" has a human face, you're protecting (in some unspecified way) those angelic wunderkind who serve Our NHS. Do your duty serf, protect Our NHS.

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"Hello I'm Unaccountable" - welcome to the guidance state

This happens in the UK too - administrative agencies and government departments from planning through the police to the NHS use 'guidance' to create rules without reference to democratic accountability:

Federal agencies issue memoranda, notices, letters, bulletins, circulars, directives, and blog posts (among other things) to evade the rulemaking process established by Congress in the Administrative Procedure Act (APA). Agencies euphemistically refer to these documents as "guidance." Guidance has been responsible for revoking permits to conduct business, barring Americans from working in their chosen occupations, prohibiting taxpayers from taking deductions, levying post-conviction penalties for crimes, and seizing property, without statutory or constitutional authority and without due process. Think of guidance as an off-the-books way for the government to ignore commonly held understandings of fairness. It's a shameless, unconstitutional scheme designed to skirt judicial review, avoid public scrutiny, and evade accountability.

Almost all planning processes rely on guidance with (often tenuous) links to the National Planning Policy Framework. ASBOs and PSPOs are framed in such a way as to make almost any action subject to arbitrary police intervention. My favourite in recent times was the police officer defending 'playing music' in a car as antisocial behaviour. I asked whether perhaps the choice of music might influence the decisions of officers to which he replied that "we would act according to guidance". Which could mean that playing The Grand March from Aida is OK but blasting out drill music isn't, we don't know because we (in this instance a Regulatory and Appeals Committee) don't have the guidance because it isn't yet written.

Among the most egregious examples of 'guidance' are in the field of human resources management and, in particular, what might be termed 'equalities'. Much of the growing denial of female spaces isn't based on regulation but rather on guidance vaguely linked to the Equalities Act and vigorously policed by campaign groups. Similarly we see gender- or race-based selection (of dubious legality) widely applied along with the active closing down of critical voices and challenges to this 'guidance'. Furthermore 'guidance' forms the basis for appeals, accusations and, too often, references to tribunal processes. And once the tribunal has decided to back the guidance (or more commonly the organisation caves in and settles) it takes on the de facto authority of a law despite never having been anywhere near the scrutiny to which laws are supposed to be subject.

The proliferation of executive agencies, public sector 'corporations' and assorted quasi-governmental partnerships has resulted in the collapse of accountability. And, with the lack of any challenge to administrative orthodoxies, the result is a system open to corruption, external pressure and a focus on 'lowest common denominator', super-safe management. The systems of scrutiny - local and national - are dominated by anything other than effective, focused scrutiny. These systems combine grandstanding politicians, policy-making by anecdote, sob stories and appeals to authority rather than a measured and analytical examination of the services supposedly being 'delivered' to the public.

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So there isn't a Brexit Dividend? (Or maybe there is...)

The decision to announce a huge bus-driven bung to the NHS has resulted less in a debate as to whether this is a good idea, if it's too much or too little cash, or cynical politics than one about whether there is (or isn't) a Brexit Dividend.

Seems to me there are three ways of looking at this question.

1. We pay over a significant sum to the European Union. For the sake of argument, let's call it £350m per week. When we leave the EU, we won't be paying over this sum of money so it stands to reason that money is available to spend on other priorities like the NHS. The only question that follows from this gives us the second way of looking at this issue.

2. Yes we won't be sending that £350m each week to Brussels but, after Brexit, we won't have all that money to bung at the NHS. In the short term there will be transitional costs, we have to consider what, if anything, replaces the agriculture subsidies, the regional development grants, and the social policy money. We also have a border to staff up, a trade department to run and ongoing costs where we decide to buy into EU programmes like Erasmus. In the short run - maybe five to ten years - there simply won't be a Brexit Dividend. It all makes some sort of sense - unlike the third argument.

3. There'll be no Brexit Dividend because government revenues will be lower as a result of Brexit. Now, leaving aside that this implies an actual decline in GDP rather than a drop in GDP growth, the truth about this argument is that it can't be refuted as it is based on the comparison of an educated guess - 'growth will be X post-Brexit' - and an actual number - 'GDP growth was X'. The problem is that the forecasters, for all their big machines and grand degree, are always wrong. And, during the debate around Brexit, have always been wrong in direction of doom and gloom. This argument can be set out simply as "we said, on very little basis or evidence, that we'd have £110 for every £100 we had back than, we've only £105 so therefore we're worse off." It isn't a good argument.

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Judgmental, immoral fussbuckets - an everyday tale of NHS management

This is, quite simply, wrong. Not wrong as in 'incorrect' but wrong as in 'immoral and indefensible':

Patients who smoke will be breathalysed to check they have given up before being referred, while those who are obese must lose 10 per cent of their weight.

Doctors claimed it was the latest example of rationing which is becoming 'more commonplace' across the NHS. The two trusts, East and North Hertfordshire and Herts Valleys Clinical Commissioning Groups, are trying to save £68 million this year.

Any patient who is obese – with a body mass index above 30 – will have to shed at least 10 per cent of their body weight before being referred for non-urgent surgery.

I know there are pressures on the NHS but singling out lifestyle choices for exclusion is not how we should respond to a lack of cash. Imagine for a moment that it's your Dad who's been told he has to quit smoking in order to have a hip operation or you Mum they're telling to lose a stone before they do her cateract operation. The people proposing these things - just to save a bit of cash - are ghastly, self-centred and uncaring, yet we're told every day how wonderful the NHS is and how it's employees are living saints. This proposal proves - once again - that the service is filled with judgemental fussbuckets.

It is time the Government put an end to NHS Trusts and Clinical Commissioning Groups implementing these policies.

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What's wrong with the NHS? Bureaucracy - that's what's wrong

Let me introduce you to the Bradford and Craven Integrated Workforce Programme's workforce strategy (this will be referred to as the IWP so often you'll forget what it stands for at some future point). The IWP - Integrated Workforce Programme - reports to the Bradford and Craven Integration and Change Board (ICB) and "aims to work collaboratively to address the commonly identified system wide workforce challenges..."

OK so far? The ICB and the IWP that reports to it works in the context of the Five Year Forward View and the Five Year Forward View Next Steps for Sustainability and Transformation Partnerships (STPs) and the work of these STPs will be delivered through new Accountable Care Systems across the Bradford District and Craven. Part of this delivery cross institutional boundaries and there is an Integration and Better Care Fund Narrative Plan 2017-19 for the Bradford District.

In amongst all this there are "a number of national, regional and local drivers and associated service strategies and plans..."

Five Year Forward View sub-strategies (GP Forward View, Mental Health Forward View etc. etc.)
West Yorkshire and Harrogate STP (WY&HSTP)
Better Health Better Lives (part of Bradford Council - BMDC - plans)
Bradford District and Craven Health and Wellbeing Plan
Bradford District Joint Health and Wellbeing Strategy
North Yorkshire County Council's Health and Wellbeing Plan
Home First Plan
Children, Young People and Families Plan
CCG Primary Care Strategies

This list is preceded by the word "including" which implies that there are perhaps some other plans and strategies not referenced.

In order to "support the delivery of the transformation agenda" there are a "number of collaboratives" which include:

Local Workforce Action Board (LWAB, WY&H)
West Yorkshire Association of Acute Trusts (WYAAT)
WY&H Mental Health Partnership
'Team Bradford' Employers Conference
Bradford Health and Care Education, Employment and Skills Partnership (BEESP)

Apparently the IWP will "ensure alignment with these enablers" and will "work on the footprint deemed most appropriate in facilitating realisation" of the plans. (Takes a deep breath).

There are some workstreams including plans for a West Yorkshire National Skills Academy Centre of Excellence for Support Staff Development and plans for a new medical school in Bradford (apparently the University has to have permission from the NHS or the government to train doctors something that further underlines how stupid this whole system has become).

Somewhere in all this soup of bureaucracy and management mumbo-jumbo there's perhaps some good work going on. The difficulty, however, is that reading the reports reveals little but an enormous and costly bureaucracy directed, in this case, to answering the relatively simple question "how do we improve the quality of our workforce, reduce turnover and meet future needs." Multiply this 'collaboration' across all the UK's myriad health bodies and the result is uncounted millions in taxpayer cash splurged on a pyramid of acronyms, plans, strategies and (new one to me this) narratives.

The NHS doesn't work. And it's only the persistence and creativity of front-line staff (most of the time) that stops the bureaucracy completely preventing anything happening at all. This isn't about funding - most cash will likely, as we've seen with Better Care Fund, result in more new bureaucracy. Indeed what is clear from any encounter with the management of the NHS is that the organisation is at its most creative when it comes to inventing new and ever more complicated systems of bureaucracy.

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East Riding CCG: Nasty judgemental fussbucketing nannies.

You're in pain. You've already waited an age for the operation. And then you get a letter from some nameless, faceless official of the NHS telling you that because you're a smoker or a bit chubby you have to wait an extra six months. Just because the bosses of that nameless, faceless NHS bureaucrat disapprove of your lifestyle.

The measures have been introduced by East Riding CCG, which has denied that it is about saving money, saying it is to "encourage and empower patients to take greater responsibility for their lifestyle choices."

This won't save the NHS a farthing. It's just being used as a painful and unpleasant stick to beat up people whose choices the scummy fussbuckets in the East Riding NHS don't like. I've no issue if a surgeon or doctor says "look mate, there's no point in me doing this knee operation until you lose some weight" or "you should quit smoking if you want this treatment to work" where the evidence is based on the actual case, the real information about a real patient. But to impose an arbitrary delay - a nasty, uncaring delay that might kill people - just to make a point about their lifestyle is worse than unforgivable, the people saying it should be escorted out of their well-paid NHS jobs because they clearly aren't suited for a caring service.

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The measures have been introduced by East Riding CCG, which has denied that it is about saving money, saying it is to "encourage and empower patients to take greater responsibility for their lifestyle choices."

Read more at: http://www.yorkshirepost.co.uk/news/health/overweight-people-and-smokers-to-be-denied-surgery-for-six-months-in-four-yorkshire-hospitals-1-8763080

The measures have been introduced by East Riding CCG, which has denied that it is about saving money, saying it is to "encourage and empower patients to take greater responsibility for their lifestyle choices."

Read more at: http://www.yorkshirepost.co.uk/news/health/overweight-people-and-smokers-to-be-denied-surgery-for-six-months-in-four-yorkshire-hospitals-1-8763080

Your caring, sharing NHS at its most cruel

I know the term 'health fascism' is pretty polemical and intended to shock. But the truth is that increasingly public health 'campaigners' (as the newspapers always call them) have created a culture around their obsessions that is unpleasant, officious and even cruel:

What happened I found out in stages - apparently someone saw me at the week-end refilling the vape from the 'sipped case' - and told them. This evening a nurse walked over to me me and said, 'what a sweet little teddy' and proceeded to play with him - 'Oh do you keep your pen in there, good heavens no its a vape'. It was so odd that I didn't twig at first. Well, I got the rules and regulations read to me in such a patronising tone of voice.

This dying woman has one small remaining pleasure removed because the rules - rules without any basis in health - don't allow it. As Dick Puddlecote points out this is a women "on a regime of intravenous Ketamine - the drug designed to stun a rampaging elephant - and Oxycodeine, but apparently nicotine is not to be tolerated." But it's worse - part of this torture is where nurses left the vape pen just out of this paralysed woman's reach.

We're told almost daily how NHS staff are wonderful and caring yet somehow we've reached a point where "as there wasn't evidence to prove that e-cigs were safe or unsafe, they were banned on health grounds" - for people in a hospice receiving palliative care for a terminal illness. Not only is this stupid but it is really cruel. So much for the caring, sharing NHS.

Since you asked, this is what I mean by health fascism.
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Why we should redirect public health funding to social care

"3-5% of people are responsible for 39% of our spending."

This is your NHS folks. The statistic comes from Bradford's three Clinical Commissioning Groups at a meeting today. Dwell on that statement for a second or two - here in Bradford just 15,000 or so people use up 40% of the money we spend on health care. Out of a population of 500,000.

There are lots of reasons for this situation and for the continuing pressures created by expensive treatment. Most of those 15,000 are elderly and in that stressful and traumatic end-of-life situation. Nobody is saying that we shouldn't spend the money we spend on that treatment.

What bothers me is that, time and time again, I'm told that the answer to this concentration of costs is to shift money from acute care into 'prevention' (or 'Tier 1' in the jargon). This is lots of jolly and cuddly stuff like fat clubs and smoking cessation clinics plus a whole panoply of annoying fussbucketry wrapped up in a thing called public health.

Think about this for a second and you'll realise one of two things:

1. This fussbucketry and huggery doesn't make a blind bit of difference. The money is wasted but also loads of people are irritated, businesses are shut down and products banned.

2. The fat clubs and advertising bans do work and people live longer. The money wasn't wasted but we still have to spend loads of cash on that end-of-life stuff. We just do it at 85 instead of 75.

For what it's worth (and this being the NHS it's worth a fortune) there is pretty much no evidence at all that tells us 'Tier 1' investment works (except in the economic sense of price hikes, bans and other restrictions impacting consumption). Yet we continue to spend millions on this - something like £10 million in Bradford alone - while moaning about bed-blocking, shortfalls in social care funding and hospital overspends.

Scrapping this sort of public health spending wouldn't solve the problem of funding care and the NHS. But it would be a damned good start.

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"We need safe spaces..." - how the NHS ducks the big questions

I can't remember the precise moment or why the subject came up but some point in 2016, in a meeting with NHS folk, something along these lines was said: "we need safe spaces to discuss the real challenges facing the health and care system". What they really meant was that some subjects are just to difficult to discuss other than in a carefully protected space - protected, that is, from the public. This answer is a reminder that our populist, planned health system is facing something of a crisis.

Before we go on to talk about the challenges we can't discuss in public we have first to talk about money. I had a Twitter exchange with someone recently where I asked what she meant by 'adequately resourced' in the context of the NHS. The answer, as these things often are, was something of a cop out but was at least better than the more usual response to such questions - a response typified by this piece of populist cant from Tim Farron:

Farron said voters had reached the stage of not believing the NHS’s problems could be solved through efficiency savings and might be willing to pay more if they were convinced it would go to the health service.

He said he did not want to pre-empt the conclusions of an independent panel formed by the Lib Dems, which will look at possible taxes to help the NHS.

In varying forms this is the default response to concerns about our health system - more taxes, more resources. The problem is that, for all that sticking a ring-fenced penny on income tax sounds good, it goes nowhere to making the NHS more sustainable. Bear in mind that, despite the claims of its founders, the NHS has required above inflation increases in funding throughout its existence meaning that it now spends approaching £120 billion out of those taxes.

In one respect our health system needs that extra cash - as Jonathan Portes pointed out recently the proportion of GDP spent on health has fallen and we do spend less per capita than other places (significantly so than the USA). But when you open the NHS up, every single element within the system will tell you that with a little extra cash they can solve this or that problem. Indeed most of those individual bits of healthcare systems - the non-clinical as well as clinical - will tell you that right now they are starved of cash meaning that people might die.

So maybe we do need more cash. But first we need to huddle in that safe space and discuss some more fundamental things about the NHS. By way of example, West Yorkshire has eight or nine general hospitals (I forget the precise number but it doesn't matter for this discussion). All of them are seen by their local community as "their" hospital and the popular expectation is that the general means they do everything that community needs. The question we need to ask in that safe space isn't how do we get more cash for those hospitals or what services do we cut to stop them overspending. No the questions are more fundamental - does West Yorkshire need all those hospitals, are they in the right places, do the facilities meet modern needs or public expectations?

We might ask, for example, why Leeds has two huge general hospitals with real access issues right bang in the city centre? Should we be finding a greenfield site somewhere more convenient and building a new large hospital? And do all those hospitals need to have high support accident units, heart care centres and cancer wards or would it be a better service to have specialised units?

I don't know the answer to these questions - or indeed to thousands of other questions about health and care provision - but I do know (because I've been given a privileged peep inside the system) that the NHS simply isn't discussing these issues at all. Mostly for fear of adverse public reaction but also because the planners within the health system are driven by issues of sustaining what's already there rather than by more fundamental questions about structure and organisation.

There's a further problem, one stemming from the very top of the NHS (indeed from the World Health Organisation), which is the belief that the drivers of rising costs are lifestyle factors especially smoking and obesity. Even when the health systems own statisticians point out that longevity is the problem, we still get strategies founded on the idea that being fat and liking a fag is the problem. This is where the proposals for limiting access to surgery come from (like this one from York) - they don't really address the problem, they're usually overturned and they make it look like the Clinical Commissioning Group (CCG) is doing something.

It seems to me that the NHS, for all the "Our NHS" and "Save the NHS" rhetoric, isn't really all that good. OK, I'll grant that it's better than a system such as that in the USA which manages to be both very expensive and to leave out great chunks of the population from effective care, but there are other approaches - Sweden, France, Holland, Singapore - that might offer some ideas about how we might improve our health outcomes. The UK has a very centralised system that is painted to look like a dispersed and localised system. As the recent round of reorganisation - called Sustainability and Transformation Plans in that jargonistic NHS way - has shown, the idea of local control or direction is anathema to the system's bureaucracy.

The Tim Farron solution - whack up a few taxes - sticks a slightly bigger plaster over the wound but doesn't address the fundamental problems (just as allowing councils to stick up council tax a bit more does solve the care crisis) in the health system. We have a health estate that was mostly designed by Victorians (to which we've added a lot of prefabs) and a structure that would do the Soviet Union proud - right down to the endlessly revisited five-year plans. Until we actually use that safe space we mentioned to discuss the real problems of the health system the NHS will carry on lurching from self-generated crisis to self-generated crisis. And worse, populist politicians like Tim Farron will go on waving the NHS's problems about as a cheap source of votes.

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Wrong, stupid and unsustainable - old people and the funding of care

Much of the discussion following the Autumn Statement concerned Brexit and the forecasts. Plus of course the prediction from the Institute for Fiscal Studies that we're not going to see "real incomes" rise until after 2021 (or something along those lines). I don't plan on making any comments about these forecasts except to say, as Chris Snowden at the IEA points out, even the much-heralded and 'independent' IFS isn't infallible when making predictions.

Instead let's talk about old people. The Local Government Association made great play of there being no mention - or extra money - for social care. It seems to me that, as Jeremy Warner observes, nearly all of the financial challenges facing government can be traced back to the inconvenient fact that us Baby Boomers (who have all the assets, or so we're told) are going to live a long time yet.

There are two reasons why people living a lot longer is a problem for government. The first of these is the impact on revenue budgets of looking after older people. Not just the very expensive end-of-life care but also the everyday costs of catering for people with declining mobility, poorer eyesight, incipient deafness and a collection of chronic but manageable health conditions.

The second is that, while we are busy not dying, the wealth we've accumulated stays safely tucked up in housing and other assets. And because we're living longer the circulation of that wealth within society is slowed down. It might be true that the explosion of home ownership post-WWII (culminating in Margaret Thatcher's brilliant right-to-buy legislation) represented the biggest transfer of wealth away from the elite in our history but right now us Boomers are sitting pretty atop all that wealth.

The proportion of the population that is over-65 is set to grow further. The ONS predicts (I know forecasts, pah) something like this:


This increase (and the corresponding stagnation in the numbers of young people) completely alters the balance of our demography. From a position where 'youth culture' dominates we are moving gradually to a sort of gerontocracy where the needs, expectations and preferences of the old vastly outweigh those of the young. It's notable that, after a time when political leaders seemed to get younger (Major, Blair, Cameron, Clinton), we now have a slew of older leaders. The two main UK political parities are led by a 60 year old and a 67 year old. Over in the USA the presidential election was fought out between a 69 year old and a 70 year old - with the 70 year old winning. If the current indications are right, France will get a 63 year old as President and Germany will keep its over-60 Chancellor.

It's also interesting to note that the question of age (as opposed to the matter of health) is never raised. When Ronald Reagan was elected his age was seen as a problem, yet no-one (so far as I can see) is challenging Trump on the basis that he ought to be getting comfy in the armchair with slippers and a pipe. This change just reflects the fact that there are millions of fit, healthy, active and involved folk in this age category. When your Dad is walking Munroes at 75 or your Mum riding at 81 then no-one's fussed about a Prime Minister who is 60 or a President of 70.

The difficulty is that our public finances (and to a considerable degree our economy) start with the assumption that people retire in their 60s and die in their 70s. When the NHS was founded its planners believed that the costs would diminish (OK they were batty) rather than increase as universal access improved overall population health. What we've seen instead is that, as health has improved, people have lived longer with the result that more and more of NHS resource gets directed to the health of old people. Today around 75% of NHS spending goes on the over-65s.

We can add the pressures on social care to these numbers - adult social care used to be an important but relative minor element in local government spending. Today it represents perhaps a third of spending with this proportion set to rise (under the current model at least) as the numbers of frail elderly increase in line with the numbers of people over 80. The current arrangement where local government contracting dominates the market for care provision results in downward pressures on costs that are simply unsustainable given rises in minimum wages and expectations in terms of service quality.

The third major element creating pressures in the simple fact of the old age pension (made more problematic by the so-called 'triple lock'). Of the current welfare budget over 40% goes on paying old age pensions and once we add in other payments such as mobility allowances, carer allowances, free TV licences and fuel discounts, nearly half of the money we spend on welfare goes to those receiving an old age pension. By way of comparison, just 1% of that welfare budget is spent on unemployment benefit.

In a world where there are fewer people working to pay the taxes to provide these benefits, it's pretty hard to see how such public largess - in health, care and benefits - can be sustained. Something has to give especially when it is clear that wealth is increasingly retained by the older generation, primarily in the form of those housing assets obtained during the great home ownership boom from the 1960s to the 1990s.

I don't believe that the answer to all this is the sort of anti-Boomer rhetoric of the Resolution Foundation where the fact of those assets (and the fortune of the increases in those assets' value) is seen as some sort of selfishness on the part of people aged over-55. Nor do I think that the answer lies in inventing a new tax so as to carry on with the market-fixing methods that result too often in expensive and poor quality social care. What is needed is an apology, some honesty and a better market.

First the apology. Aneurin Bevin lied to you and every subsequent government regardless of its political stripe has repeated and compounded that lie. National Insurance, for all the trappings of an insurance scheme, is just an income tax. So when people say, "I'm entitled, I paid my stamp all those years" they are merely repeating Bevin's lie. The government should stand up and apologise for this lie.

Next some honesty. People aren't stupid and can deal with facts so perhaps we should give them some. Starting with the one where we say that we can't go on with above inflation increases to the NHS, to social care and in old age pensions. That means we've either less money for other things that matter like policing, defence, firemen, roads and schools, or else your sons and daughters (the one's you're helping out because they struggle to buy the school uniform) will have to pay higher taxes. So old people with lots of money tied up with high value property assets need to start thinking about how they use those assets to provide the care and health support they'll need as they get older and more frail. This means no more "family house" nonsense and no more assumption that the Council will pay so you can leave those housing assets to your children.

And the market. Markets are very good at providing the things that people want. This isn't about ownership it's about how prices are set. Right now the UK's health and care system is (see above) unsustainable. Getting wealthy people to realise they are responsible for their own life is a start but, if we do this, we've got to have a market where they can purchase the care and health support they need.

None of this is about Boomers being selfish. After all part of the problem is that the Boomers' kids are anticipating the glorious day when that South London semi turns into £750,000 cash and some don't want any rapacious care homes, stair lift companies or walk-in shower fitters spoiling the prospect of this lovely lolly. A few weeks ago I was told by a housing officer how equity release schemes to improve home warmth were often blocked by families who saw this as eating into the inheritable asset. It's shocking but true that people will leave granny cold with no handrail on the front steps so as to keep ten or twenty grand on the inheritable value of granny's house.

At the core of all this is changing our presumption that care is some sort of absolute entitlement rather than something that's a matter of personal responsibility. When I sit in Bradford's Health & Wellbeing Board meetings is hear about the idea of 'self-care' - essentially people taking responsibility for their own health. Often this is little different from good old nannying fussbucketry -don't smoke, change your diet, cut out the booze, do more exercise - but it has within it the idea that we are, as individuals with agency, responsible for our own lives. And this means paying for stuff. The long term implication of self-care for an informed public taking decisions that reduce health harms and, recognising that some support in inevitable at some point, being prepared to pay others to help deliver that self-care.

In a nation obsessed with the idea of a "free" National Health Service, it's going to prove difficult to deliver the changes to our attitude to health necessary if longevity isn't going to turn almost all of government into a health care provider. And the core of all this is to recognise (or rather rediscover some we once knew but has lost sight of) that the assets we accumulate during our lives - houses, pension funds, cash savings and so forth - are there to be run down during our old age not something to which our descendants have any sort of entitlement. Getting the government to tax relatively poor people so you don't have to use your assets has always been wrong. Now it's wrong, stupid and unsustainable.

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Is it Our NHS or Their NHS?

I'll start with a little celebration. A senior finance officer from our local NHS presented to Bradford's Health and Wellbeing Board. Now if you'd made a habit of reading Twitter or The Guardian you'd be very worried at the content of this presentation - the pain, the stress, the cuts....AUSTERITY!

The officer opened with this (I paraphrase from my notes but it's close enough):

"The NHS has £800 million to spend across the three CCGs. This number is not going down but is rising. However, it's not growing at the pace we think we need to meet demand."

This, dear reader, is the truth about the NHS. When you see parades of nurses waving banners about 'saving the NHS', you're led to believe - it's implicit in the protest - that the health service is suffering draconian cuts when the truth is that the rate of growth for the NHS simply doesn't keep up with the growing pressures. And every report, each presentation we see from the officials of the NHS repeats the need for system change - words like co-production, self-care and prevention dominate the pages of PowerPoint flashing up on the screens. And this is great.

There is, however, another theme and it is this that explains the 'Save Our NHS' campaigns and the heartrending tales of cuts and awful austerity. It cropped up in today's presentation - the first three lines in the list of economies to be made were all about workforce efficiency, pay restraint and savings in administrative staff. It's not 'Our NHS' we're saving, it's 'Their NHS' - the anger about cuts and austerity is mostly a response to the NHS applying the same cost management practices that private business and, latterly, local government have used.

This isn't to say that all is rosy in the NHS or even that it is grossly overmanned but rather that a system predicated on annual increases in costs significantly above inflation is simply unsustainable. It's not a solution - as some seem to think - to create a hypothecated tax unless you plan on making the rate of that tax increase by 5% each and every year. The solution lies in stabilising the cost base and this, whatever those banner-waving NHS employees may say, means cost controls. And the NHS's biggest cost is wages.

What we're seeing with the NHS Action Party, with the doctors' strikes and with the sanctifying of all NHS employees, is an endeavour aimed at drawing the public into defending the interests of the health service's employees. For many this is right - these are deeply caring, highly skilled people - but it covers up the truth. The reality is that, without different ways of working including those involving fewer staff, the NHS is not sustainable. None of this is about privatisation, market forces or some sort of dark and evil Tory conspiracy to destroy 'Our NHS' - it's simply a necessary process aimed at ensuring that, so far is practical and possible, we retain that central idea of a health service free to all without favour at the time they need that service.

Here in Bradford the forward look at NHS finances tell us that, without changes to the way we work, there will be a deficit of over £200m by 2022/23 - this scales up to a national deficit of £20 billion. It doesn't require much analysis to conclude that this simply can't be met. So the result is that we have to make these cost savings and since over 75% of NHS costs are wage related, the biggest chunk of those savings has to come from staffing. The impact of strikes, protests and campaigns won't be that these reductions don't take place but rather - as with almost every campaign of this sort in recent history - with the resultant cuts being more extensive, more painful and more damaging.

If you want it to really be Our NHS then you need to start by rejecting the militant 'Save the NHS' campaigns and instead support a considered, rational and planned approach to reforming the NHS. This means better use of technology, it means partnership with the private, charitable and voluntary sector, it mean promoting the idea of healthy ageing and it means working with local councils to improve case - at home and in the community - for the elderly and disabled. It cannot mean supporting current structures, systems and staffing levels - if we do that we will be the losers as the NHS fails to meet our needs and the needs of our neighbours.

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In which we are reminded that the NHS management don't understand economics

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It starts with this:

‘Collectively and cumulatively [these actions] and others like them will help shift power to patients and citizens, strengthen communities, improve health and wellbeing, and – as a by-product – help moderate rising demands on the NHS’

This is the rather ghastly sounding 'Health as a Social Movement' line in the NHS's vain attempts to pretend that preventative medicine will 'moderate rising demands'. What is most striking here is that, yet again, the basic economics of all this are overlooked (although given they've appointed the risible joke of a think tank, New Economics Foundation, it's pretty clear they're not remotely interested in actual real economics).

Unless the project is about improving productivity through these community-focused actions then the only impact - assuming they do improve health and wellbeing - will be to increase the long-term demands (and hence costs) on the NHS.

The report ...projected that people with Type 2 diabetes who participated in a disease management program to prevent serious complications would cost the federal government slightly more money over 25 years than they would have without any intervention.

If you stop and think about this for a second, the reason for a healthy community being more expensive is pretty obvious - most of the costs in the health system (and the care system too) are directed towards older people so if more people live to a ripe old age there are more of those 'end of life' costs.

To use a big example, we've seen a massive decline in the numbers of and in survival rates from heart attacks - since 2002 the mortality rate has more than halved. In simple terms this means there are double the number of long-term heart 'patients' compared to the old days when they all died of a heart attack. This absolutely brilliant and a credit to doctors, pharmacists and the health benefits of a bigger, richer economy. But it's costing the NHS a fortune.

And it's not just heart attacks but every sort of disease, from childhood infectious diseases through to cancers, that has seen declining mortality rates. And this means it's pretty normal to live into your 80s, not unusual to make it to 90 and increasingly common for folk to make it to 100. So when we act - quite rightly - to prevent disease and reduce mortality rates the result is more and more old people and more and more demand for the NHS services that are under so much strain.

The challenge for healthcare is to improve productivity - to reduce unit costs for operations, for providing care, for dispensing medicines, for all the vast array of stuff health care does. And spending money on "health as a social movement" only does this if it means that the allocation of NHS resources to these communities is thereby reduced. So long as we focus on simple prevention as a demand management tool, we will find no benefit in higher productivity and a pile more demand-led costs for the system.

This is, of course, what you get if you believe that NESTA, the RSA and New Economics Foundation are the sorts of organisations that are able to guide the NHS towards greater efficiency and higher productivity. A load of left-wing cant and absolutely no moderation of rising demand.

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In which Labour becomes the NHS Action Party

In the run up to last year's general election a bunch of self-important left-wing doctors set up a thing called the National Health Action Party:

We believe a political party is needed to defend the NHS and its values. The NHS is more than just a structure for the delivery of healthcare. It is also a social institution that reflects national solidarity, expresses the values of equity and universalism, and institutionalises the duty of government to care for all in society. The NHS marks out a space in society where the dictates of commerce and the market should be held in check. We are fighting now to ensure that it is patients not profits that are the driving force behind our NHS. We hope you will join us.

In truth, this party was simply a vehicle for activists within the NHS to defend the interests of people who work - and profit from - the NHS. They targeted a few high profile politicians (the prime minister, the health secretary and so forth) and garnered the grand total of 20,000 votes with over 7,000 of those going to the former MP for Wyre Forest (in that constituency). The party's top cheerleader, Clive Peedell got 600 or so votes in Witney.

The National Health Action Party is still out there banging the rocks together but its relevence - in so far as it ever had any - had paled. Indeed it seems at times that with Labour now only having a poll lead on the NHS, that party has shoved aside the 'NHS Producer Interest Party' as I prefer to call it. Others have noticed too:

To put it brutally, we often give the impression that we'd prefer it if everyone could just work in the public sector, and ideally for the NHS. When we talk about self-employed people it's often as if we believe they must have been forced into it. We pay scant attention to arguments around competitiveness, especially global competition, and even where the evidence of competition working well is all around us (have you seen how cheap broadband is these days?) we are reluctant to acknowledge it. For some “competition' itself is a dirty word.

This is where Labour has got to and it has everything to do with who owns and runs the Labour Party. We look at Jeremy Corbyn, laugh at his political antics, and assume that a different, moderate leader would make all the difference. We point at a bunch of impressive younger MPs saying that they might be leader - Jess Phillips, Stella Creasy, Michael Dugher, Mary Creagh - but fail to ask where the policy platform will come from, whether those putative leaders will recognise that basing your politics on producer interests, albeit public sector producer interests, repeats the mistakes that led to 1979 and the destruction of 1983?

Labour's problem isn't a lack of intelligent, capable centre-left MPs but rather that the Party's policy platform is controlled by public sector producer interests. Opposition to more open international trade in services, for example, derives not from any valid economic argument but from the fear that the public sector managers who control the Labour Party will have to justify their effectiveness in a competitive environment. At the same time Labour has no idea - not the slightest inkling - how the private sector operates, what it's actually like to work in this sector and why most workers reject the stifling dullness of public sector work in favour of riskier but, in the end, better rewarded private sector work.

Until the advent of Tony Blair's New Labour, Britain's mainstream left-wing party had always been the vehicle for producer interests primarily through the trade union movement (which, of course, founded the Labour Party). Hence state monopoly, protectionism, price intervention and a host of anti-competition regulations badged as "workers rights". Today, with the trade unions all but extinct in the private sector, the Party's battle is wholly about defending the interests of public sector workers. The idea that, through new technology, innovation and efficiency, we can deliver the same public service outcomes is as much anathema to today's Labour as they were to the old Luddite union-led party - the one that crippled our manufacturing base and destroyed those communities they now mythologise.

What New Labour did - and what the Party has now rejected - was to recognise that the British public are, first and foremost, consumers in a consumer society and that their preference is for access to those consumer goodies the hair-shirted hard left sees as the baubles of late capitalist decadence. By rejecting this commitment to making the consumer society fairer, Labour has turned its backs on the idea that economic growth can - and usually does - mean a better world for everyone. Especially where there is a party not tied to crony capitalists and rent-seekers able to ensure the milk and honey of that richer land flows to all who live there.

Today's Labour Party - underneath the shouty rhetoric about 'austerity', 'equality' and 'fairness' - is a party that rejects competition, choice, innovation and efficiency. A Party that places the interests of those who work in the public sector - not just the low paid cleaners, road sweepers and caterers but well-paid administrative staff, 'fat cat' NHS bosses and, of course, the miners of the modern Labour Party, doctors. The Party - just like Clive Peedell's National Health Action Party - isn't interested in challenging the way the NHS works but rather in coating the whole thing in the aspic of changelessness, in the deranged assumption that Bevan's back-of-an-envelope fix can't be improved upon. The Labour Party has become the NHS Action Party.

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Whose NHS is it really?

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We hear it time and time again. Repeated almost ad nauseum.

"Save Our NHS"

"It's Our NHS"

"Protect Our NHS"

All this, in the ultimate marrying of popular culture and political sloganising results in a bunch of NHS employees forming a choir (helped by the chap off the BBC), releasing a sinlge and getting the Christmas Number One. Helped along the way by Justin Bieber and every second tearful person on social media.

On Christmas Day, five minutes before the Queen’s speech, a video displaying the best of our NHS was played on BBC1’s Top of the Pops. For better, for worse, for richer, for poorer, in sickness and in health, ran the messages on the screen as scenes of the NHS in action played out. It was a poignant moment for all who were involved in running the campaign - our song had got to No 1.

I'm really pleased for the people who were involved in this 'campaign'. It's always fantastic to see a project succeed, a message crack through the shell of public resistance, make a difference. But it got me thinking about 'Our NHS' and whether it sends out the right message. For sure we can show thousands of examples of how the brilliance of doctors, nurses and other medical folk, the smiling faces of families as their loved one pulls through, of mums delighted as their child's eyes open again, and of seemingly miraculous applications of medical technology to saves lives.

But is this really what "Our NHS" is about? Surely those same live saving, uplifting scenes are commonplace in every hospital everywhere? Aren't medical miracles performed by doctors and nurses in France, in Germany, in Spain - even in India? Places where "Our NHS" doesn't exist? And all these places - all these systems - are less than perfect, filled with error and mistake, lacking in resources and subject to failure? Just like the NHS.

The word 'our' implies possession - collective possession for sure but still possession. I wonder whether I - as a mere customer - can truly call the NHS mine. I do not control or influence its actions or activities beyond that moment when I put a cross in a box on a ballot paper every five years. I have no choice - there is only one NHS, that's it, like it or lump it. Decisions about when it's open or closed, about where it's located, about what services are available - these decisions are political decisions made (in theory if not in fact or reality) by those MPs we elect. We no more possess the NHS than possess the police force or the army. It is a huge, unaccountable bureaucracy directed by ministers and the officials they (sort of) employ. It really isn't ours yet the lie that this is the case is central to sustaining the NHS as Britain's sacred organisation.

Instead of talking about 'our' NHS, those doctors, nurses and so forth should be speaking of 'your' NHS. Where 'your' means the patient, the customers, the 'service user', the ordinary member of the public. If the NHS is to mean what these people claim it means then that is where the ownership should lie. But it doesn't and we are conned into believing that 'Our NHS' somehow means something - our heartstrings are tugged, the emotional buttons are pressed and, lo, the interests of those who really control this organisational behemoth are duly served. All those people who, sparkly-eyed, extol the virtues of 'Our NHS' are patsies for the nearly millionaire consultants, the trust bosses with their jaguars and barn conversions, and the 'system leaders' whose every act is to resist any change to an organisation that, for all the efforts of front line staff, fails far too many people.

It's 'Their NHS' and we shouldn't forget it. The 'Our NHS' campaigns do not serve our interests.

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Quote of the day - on the accountability of the NHS

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In Christian Niemietz's 'Diagnosis: Overrated' is this observation:

The idea that the NHS is run by ‘the people’, as a joint endeavour, is a romantic fantasy. The NHS is an elite project, and this could not be otherwise. Collective choice is not a substitute for individual choice and ‘voice’ is not a substitute for ‘exit’. The illusory ‘accountability’ mediated through the political process cannot come anywhere near the accountability of a marketplace, or of a properly designed quasi-market setting, in which providers stand and fall with the choices consumers make, and depend on them for their very economic survival.

Anyone with experience of the NHS's sclerotic organisation will know this to be absolutely true.

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It's time that NHS management started earning those big bucks they get paid

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It's a couple of weeks before the latest 'comprehensive spending review' so we can all understand the explosion of shroud waving, sorry tales of budget cuts and screams of 'crisis, crisis'. Indeed I've indulged (I think rightly) in a little bit of this myself.

However, we need to think very carefully about what we mean by 'crisis' - as in 'the NHS is facing financial ruin':

By next year, hospitals’ deficits may have escalated to such a degree that the NHS could face widespread financial collapse.

Now it's true that hospitals (and the writer is Chief Executive of a hospital trust) are facing something of a problem. We saw recently that the total deficit has reached over £800m and that most of them report continuing pressures on delivery. But Christopher Smallwood, the writer here, is just scaremongering as part of a timely lobby.

The inference in these arguments is in two parts - first that hospitals are the NHS and second that the problem is a consequence of cuts to the NHS budget. Neither of these two suggestions are right - hospitals are responsible for just about half of NHS spending and expenditure on the NHS is programmed to rise (funnily enough by the £8 billion the NHS said it needed and the government promised).

The problem here is that while the Department of Health has a specific amount of cash allocated though the national budget, this doesn't apply to hospitals - NHS Providers in the jargon - which operate on a tariff system and mostly get paid according to how many operations (or whatever) they undertake. As one consultant put it to me - 'each time a new patient arrives in hospital for an elective procedure it's "kerching, kerching".

The problems with this system are many and varied but the most egregious is the widespread belief in hospital management that fewer patients means less money for the NHS. The managers (who really should know better) think that because their hospital gets less money this means that the whole system has less money. And this gives rise to one of the more pernicious criticisms of extending the choice of providers in the health system - 'cherry-picking':

Around half of all NHS-funded hospital care – about £40bn a year – is paid for through a national tariff, where hospitals are paid a set rate for each patient, depending on the treatment given. As private hospitals generally do not treat complex or emergency patients, critics claim private contractors can profit by “cherry picking” easier patients.

What you need to understand here is that we're being told (by those same people complaining of inadequate funding) that the NHS should commission more expensive provision through general hospitals because otherwise those hospitals, in some way, would be less viable. Instead of purchasing elective surgery from the lowest cost provider meeting the necessary high standards, we are commissioning from general hospitals on the false premise that the more cost-efficient approach would cost the NHS more money.

The central issue for the NHS - and one of the reasons it has failed to meet (or even tried to meet, in truth) its efficiency targets - is that the dominance of general hospitals over the system has made it nigh on impossible to develop a market of specialised providers or to shift low-risk procedures into primary care. The moment these systems start to reach the point where their impact on the system is positive (ie releases more money for other NHS activity) the result is NHS Trust deficits giving the impression that there is some sort of crisis. This may or may not be the case but so long as the hospitals' budgets assume utter market dominance, we will continue to fail in making any meaningful efficiencies in the NHS. And there'll be this gun pointed at the government's head:

The choice is stark: more money every year or a sustained decline in the standards of healthcare and a financial collapse. How much more money? Even if the efficiency gains achieved in the next five years matched those of the past five, the government would need to increase annual budgets by £2bn-£3bn a year between now and 2020 to preserve standards. But since the NHS cannot continue to raise productivity at this rate, at least £4bn a year extra will be necessary, starting in April.

When I look at what local government - for all its faults and failings - has delivered over the past five or six years, I am forced to assume that these same opportunities exist in the NHS. But I - like the government and the public - would like the management of the NHS to make those changes without the blunt instrument of actual cash budget cuts. So far that management has avoided anything that requires structural changes and have resisted - to cries of "no privatisation" - any substantial attempts to use the private sector to help develop a significant and innovative delivery of high quality elective surgery and treatments.

I'm prepared to defend the high salaries of NHS management but that, I think, gives me the right to tell them that they need to up their game. If we're going to pay NHS Trust bosses £200,000 or more then those bosses need to start showing the creativity, innovation and invention those big bucks are paid to secure. And the message to people like Christopher Smallwood is to stop waving shrouds and start to make the case for a dynamic, flexible and responsive system - even if it means there are fewer huge general hospitals and more small, specialised and independent providers.

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"A spokesman says..." On NHS executive pay and accountability

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A couple of days ago our local paper contacted me following the latest batch of Taxpayers Alliance agitation about the pay of senior executives at Bradford Council. Quite right to make the challenge - this is, after all, public money. My response (given that I really don't agree with the Taxpayers Alliance on this one) was:

Councillor Simon Cooke said while he had "a lot of time for the TaxPayers' Alliance", it was time the campaign group recognised that billion-pound-turnover organisations like Bradford Council would have well-paid chief executives.

He said if the council didn't pay competitive salaries, it would lose its "very best people" to the private sector.

He said: "The argument is really marginal to the costs of the council to the taxpayer.

"They keep repeating these things time and time again. It's really not the kind of line I'm happy with at all.

"I don't think anyone who works for Bradford Council - and this is not a reflection of the quality of their work - is overpaid."

You don't have to agree with me. And remember that those big salaries are all agreed by us as councillors - we vote on them at full council meetings. It's open and transparent - if you don't like what we decide, you have the chance to elect someone else.

Today I'm reading the same story only this time its the NHS.

Figures for Bradford district showing how many NHS employees get in excess of £100,000 revealed Airedale NHS Foundation Trust has 74 including four non-clinical employees, Bradford District Care Trust has 24 employees including three in non-clinical roles, Bradford Teaching Hospitals NHS Foundation Trust has 220 employees including its four non-clinical Trust's board members while NHS Airedale, Wharfedale and Craven CCG has none, NHS Bradford City CCG has two non-clinical employees and finally NHS Bradford Districts CCG has two non-clinical staff.

The same applies. If we want the best quality of staff then we've to pay the sort of salaries that attract the best staff. However, there's a problem - for most of these organisations no-one was available to be accountable, to respond to the Taxpayers Alliance's criticism:

"A Bradford Teaching Hospitals NHS Foundation Trust spokesman said..."

"A spokesman for Airedale NHS Foundation Trust, said..."

This concerns me - whereas criticism of Bradford Council gets substantive response from three people who are in positions to influence the decisions, for the NHS the critic is fobbed off with an anonymous 'spokesman'.

This reminds me just how the NHS is more or less unaccountable, how difficult it is to level any substantive criticism of their decision-making, and how impenetrable the system has become to anyone not granted privileged access.

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The NHS is not "ours"

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I sit on Bradford's Health and Wellbeing Board. This observation is pretty much spot on:

Dear NHS worshippers, sorry to be a killjoy, but look, the NHS is not ‘yours’, and never has been. You have no control over it. You feel like you are in control when you spin your little toy wheel, but try steering the car in any direction other than the one where it is already heading, and see what happens. The ones who really drive the car are the political class and the medical establishment. ‘Democratic accountability’ is a mirage. All it really means is that healthcare managers answer to bureaucrats, who answer to other bureaucrats, who also answer to other bureaucrats, who, after some more detours, answer to some politician. That’s democratic accountability. Feel powerful now?

The result is that healthcare delivery planning becomes an academic exercise. Nobody sat round the table in Bradford - yours truly included - feels remotely challenged, let alone worried about the decisions we might make (assuming we actually make any). We won't be held to account for those choices. The same is true for the boards of Clinical Commissioning Groups, the senior management of Hospital Trusts or any of the many other 'pseudo-business' structures and systems of accountability that litter the NHS landscape.

The result, of course, is that decisions are made very slowly. And when they are made the default is to indulge either the prejudice or the convenience of clinicians or managers. This doesn't mean every decision is wrong but it does mean that the organisation is deeply conservative preferring to sustain the structures, systems and operational principles developed for a paper-based (and smaller) 1950s NHS. It wouldn't surprise us if Sir Lancelott Spratt were to appear in the hospital corridor attended by clucking nurses and stressed looking junior doctors.

The problem isn't fat cat salaries or a glut of managers but rather than the managers getting those salaries aren't accountable for the decisions they make. So long, of course, as those decisions are made within the comfort zone of the NHS system. As a result, when really hard decisions have to be taken - closing a hospital, moving a specialist unit - they are made in a manner that absolves management from any negative consequences. Or not made at all.

Right now the NHS is busy talking up its financial problems. It has run a deficit (one that's slightly less than 1% of its budget but a deficit nonetheless). Senior managers and 'clinical leaders' are talking sternly about burning platforms, which apparently is jargon for a financially-mismanaged hospital rather than the consequence of an explosion at an off-shore oil well. And endless reams of unintelligible documentation clog up the in-boxes of those who perhaps have to make a decision at some point. These don't talk about what we actually need to have to deliver a great health system but instead consider "whole system thinking" and "effective governance". Then we're asked what a "remodelled system" would involve without having any coherent picture of the current system.

That the NHS delivers for most of us most of the time is a credit to the front line staff - those doctors, nurses and so forth that we think of as "Our NHS". But beyond this front there is an impenetrable jungle of non-accountability - that bureaucratic paperchase described in the quotation above. The primary purpose of that bureaucracy is to ensure that the 'whole system' is accountable meaning. of course, that no individual is accountable when things go badly wrong. In truth system accountability means there is no accountability.

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The NHS is not meeting its commitment to the military

For it's Tommy this, an' Tommy that, an' "Chuck him out, the brute!"
But it's "Saviour of 'is country" when the guns begin to shoot;

So it was when Kipling wrote those words. So it had been for centuries before. And so it is today. For all our talk of respecting the military, of the Military Covenant and of remembrance, too many still see the soldier as a brute, as something other than a reliable trustworthy human. And too many of those fearful folk are working in our public services:

Aircraft engineer Mark Prendeville was relocated twice by hospital staff who said his uniform “might upset people” because “we have all kinds of different cultures coming in”.

Sgt Prendeville was taken to the Accident and Emergency unit of Queen Elizabeth The Queen Mother Hospital in Margate, Kent after chemicals from a fire extinguisher got in to his eyes during a training exercise at RAF Manston.

According to his father, the 38-year-old, who has served in Iraq, Afghanistan, and Bosnia, was “dumbfounded” to be told on two different occasions to stand out of the view of other patients. He was wearing a camouflage combat uniform.

I don't know what possessed the hospital in question but there is no doubt at all that its behaviour - not just the behaviour of a particular member of staff - was utterly wrong. This is a public service and that service is covered by the Military Covenant which says:





There's not much room for discussion here and it's not enough for an anonymous spokesperson to be wheeled out giving a massaged set of weasel words:

"This employee was acting in good faith because previously, there had been an altercation between a member of the public and a different member of the armed forces in uniform."

The hospital trust is "absolutely clear that members of Her Majesty's armed forces, whether in uniform or not, should not be treated any differently to any other person,” the spokesman added. 

This is the sort of formulaic, boilerplate response used by the NHS and other public bodies when their anti-servicemen tendencies are revealed. It's not just that the hospital was disrespectful but that it ignored its commitment as a public body, a commitment set out in those words above. A commitment meant to stop those words of Kipling being true.


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There is no evidence - none at all - to justify this lastest sugar 'target'

Except, of course, that reducing the amount of sugar might be consequential on reducing total calorific intake. More to the point this selection of one 'macronutrient' as the culprit for rising levels of obesity is pretty lousy science - as if it's not possible to eschew nasty 'added sugar' and get properly fat!

"There's no medical evidence that reducing sugar consumption below 10 per cent to five per cent carries any additional health benefit - absolutely no evidence at all.

"The current average consumption of sugar is around 12-13 per cent. Getting to 10 per cent is a reasonable target and I think we should put some real effort behind achieving that first, but to come up with a new target that is miles away from what is achievable is entirely foolish - no population in the world can do that.

"Even vegetarians from India consume eight per cent of their calories from sugar and they have less heart disease and less diabetes than anyone in the world."

So says Professor Mike Lean, chair of Human Nutrition at Glasgow University's School of Medicine who I'm guessing knows a thing or two about this stuff. Now Professor Lean does say that the government has been too soft on the food industry - he may have a point but surely most of the blame (assuming that's the game we're in) rests with us as consumers.

Nevertheless, blaming sugar for obesity simply doesn't stack up for the very simple reason that we're eating a lot less of it. Here's a line from a research proposal:

Furthermore, there has been a paradoxical decline in sugars consumption in the UK and elsewhere over the past 3 or so decades and yet rates of obesity have continued to increase.

Sadly the proposers still wants to discover whether "individuals with a high consumption of dietary sugars, and in particular free sugars are more susceptible to weight gain than low consumers" rather than accepting the distinct lack of any direct causal link between sugar and obesity. In the end the truth about obesity is pretty straightforward - firstly people are obese because they consume more calories that they use over a long period of time, and secondly that most of the people labelled 'overweight or obese' are not in any way at greater risk of being ill.

Much of the debate around obesity has been a extended effort to find a demon - something or someone to blame for us being fat other than our own overeating and underexercising. The food industry, advertising, takeaways, fizzy drinks, saturated fats and sugars all get a pasting from 'public health' sorts worried about obesity. The truth is that it's a whole lot more complicated than all that but still in the end boils down to us sticking fewer calories in our gobs than we use. And we can achieve this in two ways - eating less and moving more.

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