Reflections after a holday in Wales

Pen-y-Banc Farm, Llanwrda

Eight days ago we returned from a sunny and delightful week’s holiday in rural Camarthenshire, not far from Llandovery overlooking the Towy Valley. It’s a place we’ve been to a number of times in the past, a holiday cottage set in what should be a show garden. Our hosts were the amazing Kenneth and Gill, who over twenty years have converted a run-down farmstead into a place of beauty and a haven for wild life. The reason I call them amazing is that as well as being the epitome of hospitality they have made the transformation in the years since they retired.

Across the Towy Valley

My one sadness is my inability to explore the garden intimately in my wheelchair. However Jane brings back photos from around the paths – and I am able to sit in the back garden and enjoy the view over the valley to the Black Mountain.

For us one of the joys of that part of Wales is that is relatively accessible from our home, and yet it feels remote. Crossing the Severn Bridge is not exactly like crossing the English Channel, but there’s a faint sense of that as you go through the toll booths and all the traffic signs change to bilingual, with Welsh coming first. Talking of roads, what a joy they are after the terrors of our potholed, pock-marked tracks! Even the most minor of country tracks have scarcely any potholes. The Welsh government is often cited by Tory ministers as an example of Labour mismanagement, but I have to observe that they are a hundred times better at maintaining their roads than the English administration. I guess it’s a matter of allocating funds. In England local authority grants have been cut by 49.1% since 2010. Maybe it’s because the government allows local authorities 52 times less per mile to spend on local roads than it spends itself on major roads. And it's not just the roads that the cuts affect.

Just this morning I met a chap with a very complex medical condition who needs a support worker. The funding for support has been taken away, so that he now has to pay for his carer – which is taken from his pensions. When he suggested he might do without the support, he was told that wasn’t possible, and he would have to go into a home – funded by the sale of his assets. Apart from his small bungalow he has precious few assets. Meanwhile in a neighbouring council, there’s a team of social workers in child protection, half of whom are off ill with stress. The pressure on remaining team-members is scarcely imaginable. (Think of a half-strength football team in the World Cup, with the nation's expectations on them.) Such is the human cost of economising all in the name of cutting the national deficit. The people it hurts are not those who decree it, because, of course, if anything goes wrong, they'll not get the blame.

Aberaeron

Carreg Cennen Castle

How it is that Wales manages to maintain all its roads so much better than England, I don't know. Perhaps there's a strong lobby of Geraint Thomases. Certainly we met a road race of lycra-clad cyclists on the road home. (By the way, am I the only one to mourn the passing of leisure cyclist in normal clothing on normal bikes?) Nevertheless I'm grateful to Wales that I'm still able to enjoy its excellent roads, its beautiful gardens and castles, and its coast. We'll be back.

General election seen from a riser-recliner chair

I listened to two items on the radio this morning.  The first was an interview with Sir Andrew Dilnot and the second was a reading from Henry Marsh’s Admissions.  And I can keep quiet no longer.

Sir Andrew Dilnot, economist and the country’s leading expert on social care (You may remember his authoritative and widely welcomed report on the subject, which broadly recommended a national insurance scheme to take away the fear of the cost of care in old age - https://mydonkeybody.blogspot.co.uk/2011/07/medical-day.html), was commenting on the imminent Conservative manifesto proposals concerning funding for the elderly.  You can hear the interview here - Today programme, at 1 hour, 10 min in. He was measured and he was scathing in his assessment.

According to a newspaper account, ‘Theresa May’s social care package fails "to tackle the biggest problem” facing elderly people, the man who carried out the coalition’s review into service in England has said.

‘On the election campaign trail the PM had said politicians could no longer “duck the issue” and that the Government had been “working on a long-term solution” for the needs of an ageing population. 

But Sir Andrew said he was “very surprised” by the new thinking from Downing Street. “New thinking that I’d argue shows a less than full understanding of the problems when there is a green paper that is due to come out later this year,” he added.

‘Speaking on BBC’s Radio 4 Today programme, Mr Dilnot, who is also a former head of the UK Statistics Authority, said: “The disappointment about these proposals that we’re expecting to hear in the Conservative manifesto later is that they fail to tackle what I’d argue is the biggest problem of all in social care, which is at the moment people facing a position of no control.

“There is nothing you can do to protect yourself against care costs; you can’t insure because the private sector won’t insure it and by refusing to implement a cap. The Conservatives are now saying that they are not going to provide social insurance for it, so people will be left helpless knowing that what will happen is that if they are unlucky enough to suffer the need for care costs they will be entirely on their own until they are on their last £100,000.

"The analogy is a bit like saying to somebody you can't insure your house against burning down. If it does burn down then you're completely on your own; you have to pay for all of it until you're down to the last £100,000 of all your assets and income," he said.’

(The Independent)

Someone whose political views are unusually well-informed and reliable messaged me this morning. “Cruel, cruel Conservatives! Sir Andrew D very good on it on Today. Cost needs to be socialised not put on individuals like this."

And he’s right. It’s not just social care which is at risk. Henry Marsh is an eminent neurosurgeon. His book, Admissions – a life in brain surgery, was published a fortnight ago. He retired from the NHS in 2015. In today’s reading he recounted a day’s operating list, of whom the fourth was a lady with diabetes. It revealed the unsustainable pressure that “efficiency” and “targets” have increasingly imposed on the service. The result for one patient was fatal, and for one operating team clearly traumatic. The episode ended with him breaking the news to the family:

‘… I wanted to scream to high heaven that it was not my fault that her blood sugar level had not been checked upon admission, that none of the junior doctors had checked her over, that the anaesthetists had not realised this. It was not my fault that we were bringing patients into the hospital in such a hurry that they were not being properly assessed. I thought of the army of managers who ran the hospital and their political masters who were no less responsible than I was and who would all be sleeping comfortably in their beds tonight, perhaps dreaming of government targets and away days in country house hotels and who rarely if ever had to talk to patients or their relatives. Why should I have to shoulder the responsibility for the whole damn hospital like this when I had so little say in how it is run? Why should I have to apologise? Was it my fault that the ship was sinking? But I kept these thoughts to myself and told them how utterly sorry I was that she was going to die and that I had failed to save her. They listened to me in silence, fighting back their tears. “Thank you, doctor,” one of them said to me, eventually.’

It happened last night that a group of us were enjoying each other’s company in my favourite coffee shop, the Cornerstone Café in Grove. We were talking about the questions we’d like to put to candidates in our local hustings on 1^st June, and I found myself concluding that Labour was more likely to provide adequately both for health and social care – and more surprisingly that their financial plans were not as daft as the corporate media would have us believe. Nationalising utilities does not increase national debt, in that they become national assets, like a house (or recovering the family silver). Borrowing for investment when interest rates are at an all-time low makes good sense. Raising tax revenues from corporations and the wealthiest 5% in society doesn’t wholly work only if those firms and individuals decide they don’t want to contribute to the common good and set about avoiding or evading their share. Sir Andrew’s comment about the social care proposals is relevant. 'Mr Dilnot said he was “very disappointed” by the proposals in the manifesto. “Not personally. I feel very disappointed for all of us – the millions of people who are very, very anxious about this,” he added.'

I guess that’s what all of us have to decide, captains of industry, the comfortably off, those with no jobs and those who depend on benefits and food banks - and everyone in between. Will we care about the millions or will we care just about ourselves? It’s all too easy to think, “I’m all right, Jack. The rest can go hang.” The issues are really too important to be reduced to schoolyard name-calling and character assassination.

The NHS Mandate

Jeremy Hunt, Secretary of State for Health, has, I hear, agreed to go (or send his minions) to talk to the junior hospital doctors at ACAS, the reconciliation service - at last. It takes a long time, it seems, for ministers to listen. So it was with a certain amount of scepticism that last week I read and tried to understand the Government's consultation document on the future of the NHS, and then filled in the response form. I found out about the consultation only after reading about a Guardian article on the subject by Ann Robinson, not thanks to the Government making it known. I received an automated acknowledgement after I'd submitted my response. I wonder, actually I very much doubt, whether any human being, besides you will bother to read it, let alone take any notice of it. Already Mr Osborne's Autumn Statement has had implications for health and social care provision in the local government settlement, which close down investment.

Anyway, here is is my response:

1) Do you agree with our aims for the mandate to NHS England?

I disagree with a number of implications in the priorities and aims: 1.    That ‘preventing ill health and supporting people to live healthier lives’ is only the remit of the NHS. If other budgets are cut, e.g. education and social care, than that aim cannot be achieved. 2.    That the present GP system does not provide good 24/7 care. As a patient with a chronic illness, this has been far from my experience. This aim appears to militate against small GP practices. 3.    Defining as ‘long-term’ a mandate lasting ‘three or more years’ invites the possibility of continual uncertainty and upheaval to the service. It needs guaranteed stability. I would question also the assumption that the patient knows best implied in the priority: ‘People should be given more power and control over the care that is provided to them’ whilst agreeing that it should be that ‘services are arranged around their needs and they are supported to manage their own health.’ I agree that the mandate should be clearer and more accessible to the public.

2) Is there anything else we should be considering in producing the mandate to NHS England?

Clarity and accessibility means avoiding language incomprehensible to the public, such as: ‘in-year deliverables and metrics to measure progress’ whose meaning eludes an English graduate.

3) What views do you have on our overarching objective of improving outcomes and reducing health inequalities, including by using new measures of comparative quality for local CCG populations to complement the national outcomes measures in the NHS Outcomes Framework?

The aim of increased transparency is a laudable one, but it needs to be accompanied by increased trust, particularly of health professionals. The aim of delivering equally good service nationwide is also clearly desirable. There is a danger in this target-driven objective of unfairly stigmatizing skilled professionals in challenging situations and driving them away from where they are most needed. There is a further danger of diverting professionals from their primary calling of care into a culture of form-filling. This is counterproductive in the pursuit of excellence. There is also a danger of league tables being used as ammunition in political argument, which ultimately demoralises rather than encourages. This is the stuff of bad management.

4) What views do you have on our priorities for the health and care system?

In headline terms, your priorities are ‘motherhood and apple pie’ You want to create a healthier society, particularly focusing on younger people. However, this seems less a function of the NHS than of Education and recreation. Dementia care and research is clearly an increased priority. I am glad the government wants to put effort into those – as well as other areas of mental health. The neglect of mental health ought to be redressed; but this will need considerable financial investment both in the NHS and in community social care. Transparency and simplicity from the patient’s perspective is desirable. However the security of digital records also needs to be paramount. The government’s principle should be to rein back on centralised record-keeping, rather than extending it. The citizen’s privacy should normally trump efficiency. Retelling one’s symptoms is a small price to pay for individual liberty. However, creating new rights, such as the ‘right to a specific named GP’, runs the risk increasing the burden of litigiousness surrounding the medical profession as does the comparison of the health service with the airline industry – with the possibility of suing for late appointments for example. The healthcare industry is entirely different from a commercial enterprise, and should not be shoehorned into becoming one. Whilst I am in full agreement with the aim of preventing ‘avoidable ill health and premature mortality’, I think the assumption that increasing longevity is a desirable aim should be questioned. Officiously prolonging life is not a great good and should not be ‘a metric to measure progress’. Good end of life care, however, should always be a top priority.

5) What views do you have on how we set objectives for NHS England to reflect their contribution to achieving our priorities?

As already indicated, I have some reservations about the possible implications of where the objectives are specific. Otherwise they seem general enough to be open to whatever interpretation is required by policy makers. I do notice the final objective for the NHS to make money, or to be involved in its generation. Finally it needs to be said that this consultation process is particularly opaque. The consultation document is not easy to follow, what the questions are asking isn’t obvious and where to send this response form is equally unclear. You could for example simply say, ‘Thank you for taking the trouble to complete this form. Please now send it to mandate-team@dh.gsi.gov.uk.’

Predictably bonkers

Oh no, not again! First Dilnot. Now Leveson. Faced with a crisis, whether the cost of social care or the collapse of trust in journalism, David Cameron sets up a commission or an enquiry, under distinguished and extremely intelligent experts, who spend many months of intensive work of evidence-gathering and deliberation. They then come up with long reports with workable conclusions.

Then in Parliament the Prime Minister makes polite noises about the reports as he presents his verdict. But when it comes down to the nub of the matter he weaves and ducks. What a shame! In the case of Dilnot, the Government has been dithering about the limit of contribution towards social care that people should be expected to make. The suspicion of course is that HMG wants to set it higher than Dilnot's recommendation, to reduce its own perfectly affordable input. The effect of that would of course be to penalise those with modest savings, as they'd lose a larger proportion than those with fat-cat pensions.

And now with Leveson the plan is to present a bill to Parliament which, as the Culture Minister, Maria Miller, admitted to John Humphris on the Today programme, is designed to prove Lord Leveson's proposal unworkable. Unsurprisingly virtually all today's newspapers have been rubbishing the report. When you come to think of it, that's a pretty strong recommendation for it. They don't want to see their licence to kill reputations, privacy and even worse curtailed - and that is what they fear a more independent effective regulatory body might do. In Parliament time and again we heard the old canard that Lord Leveson was proposing state regulation of the press, the myth which that same press is very busy promulgating. It is clear that he is not. He is proposing that someone guards those who are keeping an eye on the guardians of our freedom.

Lady Helena Kennedy QC, the great champion of free speech, compared the Prime Minister's rejection of Leveson's central recommendation to a genuine Whitehall memo that followed the last enquiry into press standards by Sir David Calcutt 20 years ago. "We know we're not going to do anything. We can't say we're not going to do anything, so we have to say something that covers up the fact that we're not going to do anything." As she said, it could have been a line out of Yes, Minister. The tragic thing is that "not anything" means nothing for people like the Dowlers and the McCanns. David Cameron assured such victims that he would ensure the implementation of Lord Leveson's proposals "unless they were completely bonkers". Apparently he reckons they are. Most of us know they're not, and wonder whether our politicians have learned anything from the past few years.

Why the picture at the top of this piece? Well, you know what they say about kicking things into the long grass... One way we can try to prevent this happening to the Leveson report is signing the petition launched today by Gerry McCann and Chris Jefferies, the traduced teacher from Bristol:   http://hackinginquiry.org/petition/.