Last week Andrew Lansley, the Health Secretary, published his white paper on reform of the National Health Service (NHS).This sets out a policy framework aimed at abolishing Primary Care Trusts (PCTs), giving General Practitioners (GPs) instead the responsibility for commissioning treatment for their patients. Having thus empowered GPs, the Health Secretary then expects them to proactively respond in making informed decisions without seemingly further guidance from the Department of Health. This could lead to the creation of large US-style, privately owned Health Maintenance Organisations (HMOs) which in practice have driven up costs without correspondingly fair and reasonable improvements in US healthcare.
In fact, over the past two years under a practice-based commissioning initiative under the last Labour government, GPs have already been encouraged, should they so choose, to take control of part of the local health budget. For example in Cumbria last year, six teams of GPs each serving a population of around 100,000 have worked with a shadow budget and, as of last April, have been responsible for 60% of the £800 million health budget. A mutual-benefit partnership between the public and voluntary sector is foreseen (evoking the Big Society of David Cameron?) which, e.g. in the case of their more elderly patients would involve Age UK, collocated at favourable rates with the GP team, bringing practical assistance aimed at keeping them in their own homes and out of hospital (a potential saving of £3000-4000 per non-hospitalised patient).
However, the experience gained from the earlier GP fund-holding experiment of the Conservative government in the 1990s, when it was unfortunately decided not to evaluate the actual results from the beginning, also needs to be taken into account. Although the general public received no information on whether clinical outcomes and patient safety or the cost-effectiveness of care were improved, there were suggestions that patients of such fund-holders were often reported as less satisfied with their NHS services, felt knowledge of their medical history worse than before and the willingness of their GPs to refer them to specialist treatment diminished. GPs seemed more concerned with keeping costs down rather than improving care. The complexities of contracting could also lead to any efficiency improvements being offset by high transaction costs between GPs and hospitals, the former often forced to make decisions without accurate information about the quality of the contracting services on offer. Overall, fund-holding was unable to achieve major and sustainable improvements in their hospital experience as far as the public were concerned e.g. in reducing waiting times, something that the NHS reforms of Labour did achieve and that matters to patients.
In summary, therefore, it would appear better to first test these proposed NHS reforms via a limited number of carefully selected pilot schemes, with their clinical outcomes, efficiency gains and cost effectiveness measured against predetermined but realistic targets, to foster the subsequent development and sharing of best practices.
Archive for the ‘Chairman »s blog’ Category
NHS Reforms
samedi, juillet 24th, 2010Federal EU?
samedi, juillet 17th, 2010Further to the question raised in the previous article (Turkey-Realpolitik?) on the future evolution of the EU, the weekend of May 9-10 when the Greek, Portuguese and Spanish government bond markets and banking systems came to the brink of a Lehman-style meltdown, saw European politicians take a further step towards a full-scale fiscal and political union in defence of the Eurozone.
Ignoring the no-bailout clauses of the Maastricht and Lisbon treaties which specifically forbid EU governments from collaborating fiscally to guarantee each others? debts, they created what is essentially a large federal-type, borrowing programme backed by all the Eurozone governments. This has enabled channelling of the results of excess savings from Northern to Southern Europe which, to prove sustainable longer term, should evolve into a full-scale, federal European budget to enable the poorer, less competitive regions to be permanently supported by the richer ones. This would also require the ECB to act as the lender of last resort in the classic role of a central bank, to provide essentially unlimited back-up to any associated emergency lending programmes arranged by European governments. In the longer term, the public spending and tax policies of the weaker Eurozone economies will have to become more aligned with that of Germany to allow the political outfall of such a fiscal union to become more manageable.
Such a fiscal convergence programme as part of a viable single currency union, backed by a European federal budget, is not likely to be put to wide, popular vote particularly in Germany where taxpayers would presumably be unwilling to vote for their money to support other more profligate Eurozone members. Rather this could happen as a result of normal public apathy and acquiescence, managed through political stealth as part of an inexorable but non-democratic process towards the construction of a federal EU.
Turkey-Realpolitik?
dimanche, juillet 11th, 2010William Hague the British Foreign Secretary, has spoken of Britain championing Turkish membership of the EU as part of the new foreign policy committed to building relationships with emerging economies, particularly if enjoying robust growth. Contrary to the arguments of politicians in France, Germany and other member states, he considers the EU turning its back on the membership aspirations of the predominantly Muslim Turkey as an immense strategic error.
There is concern in the West that Turkey in response, is turning its back on an unwelcoming Europe and embracing the Islamic world e.g. by voting against sanctions on the nuclear programme of Iran and embracing Hamas, considered by the US and the EU as a terrorist organisation. However, compared with the EU, the economy of Turkey is booming with 11.4% growth in the first quarter of 2010, government debt only at 49% of GDP and strong export business due partly to its closer regional ties with Iran, Syria and Russia.
Mr Hague accepts that Turkey needs to improve in areas such as human rights, competition and media freedom to support its case for EU membership but there is potential for a major increase in trade flows, currently £8.6 billion a year between the two countries. Turkey is also a key Nato ally strategically placed between Europe and Asia with channels of communication different from the West. It would also appear that with the West in financial recession, Turkey is looking towards the East to explore opportunities and exert influence with its new financial power.
The British policy towards Turkey, therefore, seems a very pragmatic piece of realpolitik which again calls into question the future evolution of the EU into a common trading bloc or free market of neighbouring nation states, a single political union based on a common Christian heritage or something in between.
Capital Gains
lundi, juin 7th, 2010Robert Chote, director of the Institute for Fiscal Studies, contributed an informative article on ?Solutions to the taxing issue of capital gains? in last Sunday?s Times (refer also to Pages/Capital Gains Tax in the righthand column index). The Liberal Democrats consider capital gains tax (CGT) as a good way of raising money for income tax cuts whilst some backbench Tories call raising it to income tax levels an attack on the middle classes and a betrayal of Conservative values. CGT is forecast to raise £2.7 billion this year, only 0.5% of total government revenue but has perhaps a key role in underpinning the much bigger revenues from income tax and National Insurance. He favours the Liberal Democrat approach which also aims to minimise the scope for tax avoidance and, given that the coalition will be forced into many unpopular measures to clear up the inherited fiscal mess over the next few years, recommends taking the opportunity of developing a more rational tax system rather than resorting to short term fixes.
Deferred Taxation
dimanche, juin 6th, 2010David Laws, before his unfortunate and forced resignation as the treasury chief secretary, put it very succinctly with his confident command of financial affairs in stating that government borrowing is effectively only deferred taxation.
It is on the tax front then where Conservative voters have been disappointed that a pre-election pledge to provide more generous Inheritance Tax allowances has now been withdrawn. Indeed the government is also bringing Capital Gains Tax into line with Income Tax, although the annual exempt allowance will apparently not be cut and the new rate is not likely to exceed 40%, even for 50% tax payers. This is the result of a policy compromise between the Tory right and the Liberal Democrat left, which includes Vince Cable the business secretary; however, it also reflects the grim reality of the government?s empty coffers.
Otherwise it would appear that the tactic to keep the coalition together is to not try and reach a compromise on every issue when each side could end up dissatisfied. Thus the Conservatives have kept the major part of their tougher policies on immigration and Europe, whilst the Liberal Democrats have their way on voting reform if MPs approve a referendum on this, as well as their zero tax band on the first £10,000 of earned income (which also suits the progressive Conservative approach to the less well-off, even in times of austerity).
Coalition Government
lundi, mai 24th, 2010Coalition government has some benefits for the Prime Minister:
– It strengthens his pre-election claim to sceptical voters that his party has modernised and indeed has now been rebranded the Liberal Conservatives, as he describes his new government.
– His Liberal Democratic partners are taking joint ownership of hard decisions on spending cuts.
– The coalition agreement also allows him to drop difficult manifesto pledges such as modifying the Human Rights Act, repatriation of powers from the EU and an inheritance tax break for the richer part of society during a budget crisis.
In addition, he still has room to move a little to the right of centre with Gordon Brown having already having shifted Labour a little to the left in cancelling the plans of Tony Blair to reform the welfare state and public services.
The Conservative right has been rewarded with right wingers such as Ian Duncan Smith appointed Minister for Work & Pensions and Liam Fox placed at Defence: the Conservatives have also secured the Home Office with e.g. the immigration amnesty of Nick Clegg having cost the Liberal Democrats many votes.
As a result, party management has become his top priority and having ignored his influential 1922 committee of backbenchers to force through the coalition agreement, he has also forced through a vote for it to accept ministers as committee members who can vote to elect its officers. However, he still needs the support of his party and natural Conservative supporters, not helped by agreeing to raise the income tax threshold to £10,000, paid for by rises in capital gains tax that will e.g. impact second-home owners. (He has even had to subsequently retreat in front of the 1922 Committee back-benchers by agreeing that after all his ministers will not be able to vote in their elections.)
Therefore, he is back talking in the media about mending the so-called ?Broken Society?, being at heart a ?low-tax Conservative? and promising to revisit the contentious issue of the 50% top tax band. This is very necessary loyalty building in the ranks with the Liberal Democrats not always natural partners for the future.
Less Tribalism
lundi, mai 10th, 2010In the end it was just too steep a hill to climb in order to completely recover the Conservative majority lost in the Labour landslide of 1997. However, now is not the time for a blame game on what might have been achieved with an aggressive approach to the election based on more traditional Conservative policies. As demonstrated by all three major parties in Westminster, the electorate in general was not judged ready for all the necessary tax rises and associated cuts in public spending required after the election to reduce the budget deficit within a time period acceptable to the financial markets. Having, therefore, retreated from their original more aggressive position on cuts the Conservatives were still able to differentiate their position somewhat and gain some traction particularly with the business world, in support of their proposed reduction in the national insurance increase of Labour. However, they failed in launching their one big idea of the Big Society which had apparently been untested on the public by focus groups and candidates also found difficult to understand, accept and, therefore, sell to voters on their doorsteps. On the other hand, the prime minister was forced on the defensive and reverted to the politics of fear and the old class warrior of the Left to shore up the traditional Labour vote. Despite surprisingly losing some seats the Liberal Democrats have emerged as the king makers and also demonstrated the power of a more simple concept with the electorate i.e. for no income tax on the first £10,000 of earned income, which also has the added benefit of attracting people off welfare support. How the Liberal Democrats proposed to pay for this was debatable but as a small example my son and daughter were sufficiently attracted to vote Liberal Democrat in their two Labour-dominated London boroughs.
Now is, therefore, also not the time for tribalism politics as the Conservative party obviously wants power and David Cameron has shown true leadership in putting the state of the British economy first in reaching out to the Liberal Democrats to secure a working majority in the Commons.
Leaders`Debate 29 April
vendredi, avril 30th, 2010Despite the economy being given advanced billing as the main topic of the third and final TV debate, unsurprisingly not one of the three leaders was prepared to specify in any detail the real extent of spending cuts and tax rises required whichever party might be in power after 6th May. However, David Cameron with his message of change after 13 years of disastrous Labour government and the need to differentiate between the economy and `Big State? Labour, maintained the Conservatives` lead over a prime minister trapped by his economic record and forced to acknowledge the difficult trade-offs required in office, such practical aspects not so popular with viewers. Nick Clegg with his more audience appealing `If we do things differently, we can build a better, fairer Britain? also continued to boost the Liberal Democrats in the polls.
Whichever party holds the majority of seats after the election will need a strong mandate to implement the measures required to restore the economy; even a Conservative – Liberal Democrat coalition resulting from an otherwise hung parliament is then likely to have the added support from the Country of a clear majority of actual votes cast.
Leaders`Debate 22 April
lundi, avril 26th, 2010Although no clear leader emerged from the second debate, David Cameron recovered his front running position from Nick Clegg and was much more aggressive e.g. in angrily challenging Gordon Brown for his `lies? when referring to Conservative leaflets as proposing cuts to pensioner benefits. He appeared more relaxed, looking into the camera when addressing the wider audience of viewers and performing as a potential prime minister.
Nick Clegg, however, even without the surprise element of last time, was still supporting the Liberal Democrat resurgence in the polls despite weaknesses in his energy policy over the use of nuclear power, on immigration when offering an effective amnesty for illegal immigrants and suffering a major put down by Gordon Brown telling him to `Get real, Nick? over national security and the Trident missile programme. He also badly handled a question about his own expenses, dismissing it as `nonsense? rather than answering it and David Cameron put him on the spot over his holier-than-thou performance in the last debate.
Gordon Brown improved as the debate went on and had his best moment in expressing his shame over the expenses scandal. He also asserted that the withdrawing of £6 billion from the economy (as identified by the Conservatives as unnecessary waste in public spending and better employed to avoid a jobs-threatening rise in National Insurance contributions) would harm the recovery with no convincing counter argument from David Cameron, the latter perhaps waiting for the final debate when the main subject will be the economy. In his closing statement Gordon Brown neatly targeted both his opponents in saying `David, you are a risk to the economy and would leave us isolated in Europe; Nick, you are a risk to our security and would leave us weak?.
David Cameron in his own closing remarks was relatively less impressive than earlier in the debate in speaking more generally about the need for new leadership and a clean break after the past 13 years of Labour government and inviting everyone to build together `The Big Society?, the first time this state-limiting policy of the Conservatives had been specifically mentioned by name during the entire debate. Perhaps the `Big Society? will be returned to in the final debate on the economy to give more practical examples and argue that there are limits to what the State can do given the budget deficit.
As the final speaker, Nick Clegg focussed more on values in emphasising doing things differently, standing up for what `we? believe in, resisting those against change and harvesting the younger vote with his `something exciting is happening?.
Policies not Personalities.
lundi, avril 19th, 2010So there it is ? Vote Clegg Get Brown! ? as far as the Conservatives are concerned, but the bounce in the opinion polls of the Liberal Democrat leader who pushed his way past a perhaps too correct David Cameron for attention, has certainly injected more life into the run-up to the election.
The Conservatives possibly too busy fighting Labour over so-called phoney, efficiency savings and neglecting the Liberal Democrats, have still to consolidate their major ideologically, different policies in the minds of the electorate and particularly The Big Society which has yet to resonate with voters. However, with no real policy details emerging from any of the parties, campaigning has seemingly been reduced to a choice between simple slogans and personalities. Here Nick Clegg unlike the Prime Minister is seen as too similar in background and experience to David Cameron to attack. From the results of the first debate he also appears to appeal more to the younger or first time voter used to interactive, TV reality shows and exchanging instantly formed opinions with their peers via Face book and Twitter.
The next debate between the main party leaders, therefore, which is on foreign affairs, needs to develop somewhat more substance and difference between actual policies and not personalities. Here the Liberal Democrat vote against the Iraq war could stand them in good stead but their policy for further integration (when the time is right) within a European Union, Super State might not play so well with the British public in general.