Martin Durkin's programme on Channel 4 last night certainly did not hold back. It was dramatic and powerful. It had some clever footage at the beginning with politicians repeatedly saying they were going to "spend", "spend" and "spend". This was followed by analysts and former chancellors drily saying that government did not have any money of its own. It was all the public's money.
I particularly enjoyed some of the visual demonstations of otherwise dry figures. There was a tall, transparent tube. Its total height represented all public servants - said to be seven and a half million. Then along came people dressed as representatives of the different front line services: a nurse, a policeman and so on. Each came with a bucket of liquid representing how many of them there are. After all of the liquid representing the front line services had been poured in, the measure had only reached just under two million people - and that included those employed in the private sector.
"So what do the other five and half million people do?" asked Durkin. There was then a mock quiz show based on "what's my line?" in which a panel tried to work out what jobs people did - often involving words like "consultant" and "coordinator".
Added 12th November 2010. It seems one can catch up on the this programme for nearly a month on this link: http://www.channel4.com/programmes/britains-trillion-pound-horror-story/4od
Here is a remarkable story of waste of resources in a publicly run service:
Just one in ten police officers is free to tackle crime at any given time because the vast majority are either off work or tied up on other duties, a watchdog report has disclosed. In some parts of the country, as few as one in 16 officers is available to see the public or pick up the phone when a victim of crime calls.
The report, by Sir Denis O'Connor, the Chief Inspector of Constabulary, also found on any one day there are just 5,000 officers across the country ready to respond to emergency 999 calls, raising fresh concerns over the police’s ability to protect the public.
The picture emerged in a detailed study of the current state of policing and its ability to survive forthcoming cuts.
It found that the average beat bobby spends fewer than half the days of the year on duty and questioned management decisions after it emerged there are regularly more officers available for duty on a quiet Monday morning than the peak hours of a Friday night.
The full story was on the front page of the Telegraph.
The study of 400 NHS operating theatres found that last year, less than 50 per cent of time scheduled for operations was actually spent performing surgery.
In orthopaedics, the biggest specialty, just 45 per cent of "operating time" was spent on surgery, while 33 per cent of time was lost to late starts and decisions to stop work early.
In ophthalmology, only 40 per cent of allocated time was devoted to operations – while 37 per cent of time was wasted at the start and end of the day.
Gaps between treating patients, cancelled operations and gaps on the surgery lists accounted for thousands more hours wasted.
The study by the NHS Foundation Trust Network examined detailed timekeeping records kept by clinical teams at 40 NHS trusts, as they performed 26,000 operations.
This story was from the Telegraph. What would be really useful, of course, is a comparison with other hospitals. How do private hospitals fare here and in other countries?
Only 18 useless teachers axed in 40 years despite '17,000 failing staff' in our schools.
From the Mail.
An organisation that does not sack some of it members has fallen under the control of the 'producer interest'. It serves its staff as a priority of serving its customers - the children.
Whatever else Labour did, they certainly made benefits more complicated.
The Child Poverty Action Group annually publishes the Welfare benefits and tax credits handbook.
How many pages do you need to read to get the picture? Well, I just bought the out-of-date 2009/10 edition because I could buy it much cheaper, second-hand, than its cover price of £37.
The total number of page is 1,601. The benefits system has become ludicrously complex.
Policy Exchange has dug out some remarkable statistics in looking at how public services have developed in recent years. It is a story of the 'producer interest' writ large. Public services have a greater tendency than companies to indulge the producer interest. Companies have to compete to survive to indulge its servants. Public services do not.
It is embarrassing to sack someone for being no good at his or her job. You avoid it if you can. If there is a desperate need for an organisation to perform well to survive and remaining profitable, the bullet is bitten. People are sacked. But in the public service, there is no such driving imperative. So incompetent or lazy people keep their jobs. The 'producers' don't suffer. The consumers and those who pay for the service suffer instead.
Here are some of the figures which back up this argument:
Over the last decade the redundancy rate in manufacturing or construction has been seven times higher than in the public sector, roughly defined. During the recession these multiples increased to 16 and 10 times respectively. In a large survey of 60 different public sector organizations coordinated by the Cabinet Office, just 13% of employees disagreed with the statement that their organisation “is too lenient with people who perform poorly here.” The Civil Service is the most extreme example of this. Less than 1% of civil servants take voluntary redundancy each year, and compulsory redundancies are even rarer, affecting less than 0.00007% of the workforce a year. Job security can be seen as a benefit for the individual worker, which might be worth a certain amount of salary.
There are many other bits of remarkable information on the pay of managers and so on in the Policy Exchange report.
One of the key reasons that state-run bodies tend to provide less in the way of service at a greater cost is the waste that tends to build up in them over the years.
People are usually aware, though they may not like to admit it, that this is true. So you have politicians declaring at elections: "we will maintain/increase the front line services".
So what are the 'front line services'. They are the services of people like nurses, who actually treat the patients. These nurses are contrasted with the bureaucrats who do lots of paperwork which, it is implicitly accepted, involves a lot of work that is not really as necessary or important as the nursing work.
So the Labour government used to boast that it had increased the number of nurses. That is doubtless true. However, what if it also, at the same time, changed nurses into semi-bureaucrats? You could say, increase the number of nurses by 15% but increase their paperwork time from, say, 25% to 45%. In doing so, their front line time would be reduced from 75% to 55%. That, if you are still with me, would me a 26.7% reduction in their front line work, per person. So, overall, even after the increase in the number of nurses, the amount of 'front line' work would fall.
The numbers I have used are not the real numbers, just an illustration of how this is possible. Here, then, is an indication of the actual proportion of time nurses may now be spending on paperwork, given by the new Health Secretary, Andrew Lansley:
“They often spend just 50 per cent of their time interacting with patients, and in some cases as little as 35 to 40 per cent, because of bureaucracy and the shift system.”
The Royal College of Nursing has repeatedly warned that nurses were being bogged down by the weight of administrative duties.
In 2008 nursing staff across England spent more than a million hours a week on paperwork, the union found, time it said could be better spent tending to patients.
A survey of nurses also showed that most believe that the administrative burdens placed on them had increased over the past five years.
The full article is in today's Daily Telegraph.
This story is a possible lead as to how it was that such a vast amount of extra money was poured into the NHS by the Labour government resulting in a relatively modest improvement in the performance of the NHS.
NHS total staff 1.43 million - up 30% compared to 1999.
Managers 44,600 up 84%
Administrative and technical support staff up 40%
Nurses 375,500 up by 'a quarter'
Junior doctors up by 'two thirds'
GPs up by 'nearly a third'
Consultants up by 'more than half'
These figures quoted in the Telegraph show that the fastest growing category of people in the NHS has been that of managers. They are ones who are well paid and do no front line work curing or caring for patients.
The Telegraph article does not make it clear where the data comes from.
Here is more information from the coverage in the Guardian,
The number of managers in the NHS in England rose by nearly 12% last year - more than five times the rate at which qualified nurses were recruited, sparking concerns that cash was being diverted from frontline staff.
Despite claims that NHS bureaucracy has been cut the health service has seen an explosive growth in management. The survey shows that the NHS now employs 44,660 managers and senior managers - an annual average increase in their employment of 6.3% over the last decade. This is faster growth than consultants, doctors, nurses and midwives.
A census by The NHS Information Centre reveals staff numbers reached 1,432,000 in 2009 - an increase of 63,300 (4.6%) on the previous year. It represents a steep acceleration in hiring. Staff numbers have grown by 2.7% on average every year over the last decade
All the main parties claim they will cut public spending. But whose jobs will go? It ought to be those of the civil servants doing work which may be desirable but is not absolutely necessary. But it is the civil servants who will be doing the sacking. They won't want to sack their own kind.
Here is a warning passage from a parliamentary debate in 1980, when cuts were being pushed through with more determination than is likely by any of the current political parties:
We have been assured on a number of occasions that, wherever possible, cuts in Civil Service manpower will be achieved through natural wastage rather than redundancies. In this instance, clearly there was a good deal of pressure on the Ministry of Defence to cut numbers, partly because it employs about one-third of the total number of civil servants. Against that background the cleaners may seem to be an easy target. After all, in the Government's statistics, as in the divine plan, one Mrs. Mopp counts the same as one permanent secretary. In this instance the axe was not spared, and it fell not on a single deputy secretary, under-secretary, assistant secretary, senior principal or principal, but on just under three and a half score cleaning ladies. It is not surprising that one or two of my constituents have suggested that the whole episode sounds as though it comes from the television programme—which I have not managed to get home in time to see—called "Yes, Minister".
The speaker was Michael Heseltine.The link is here.
This is an old blog post but illustrates the point that government regulation can actually do harm. In this case, the harm is that valuable time of doctors is used filling in government forms rather than treating patients. Link here.
The newspapers in the past few days have been stuffed like a Christmas turkey with articles illustrating the waste that takes place in publicly-owned services:
- the Ministry of Defence employs about one civil servant to every 2.25 members of the armed forces.
- the government intends to prohibit anybody without a university degree from becoming a nurse, thus increasing the cost of each nurse and reducing the number of years he or she will work.
- the top 100 staff of the BBC are paid £20m a year plus bonuses and entitlements.
- the police have issued a 93 page booklet informing its constables how to ride a bicycle.
These things are even worse than they appear:
- the money that is wasted in this way cannot then be spent on things that are actually important like more soldiers and sailors, better equipment for them and more nurses. There are already shortages now in all these areas. Nurses are already rushed off their feet and unable to give satisfactory attention to patients. This is bound to get even worse as a result of the university rule. The shortages of men and equipment in the army have been prominent in recent news.
- Secondly tax has to be raised to pay for the waste. This tax is levied on poor people, too. The government already demands taxes of those people whom it defines as being in poverty. The extra tax also means extra discouragement to those who might otherwise move from benefits dependency to employment. Without work, they have less hope and self-respect. And the cost of any decision to stay on benefits means extra taxes on those remaining in work.
Waste in public services is normal. It always happens, sooner or later. And it is not a victimless crime.
(Extract from the Daily Mail
The Ministry of Defence by numbers
85,700 civil servants at the ministry
113,000 personnel in the Army
38,400 in the Royal Navy
41,400 in the RAF
So according to these figures, there are 192,800 members of the armed forces and there is one civil servant for every 2.25 members of the armed forces.
Every six months, the government produces a list of the press officers of the various government departments. It is called "The White Book". When I first used this book many years ago - certainly more than 15 - it was a modest little affair that was stapled together. I remember being impressed by how few staff were press officers for the Treasury despite its great importance. I think it had between about seven and nine press officers. I wrote about economics at the time and got to know some of them pretty well.
The latest White Book published in September has 206 pages - the size of a short novel. The number of pages is up from 198 in the March edition - so much for the government holding spending on everything apart from 'front line services'. Naturally staples would not hold those pages together so it is bound like a paperback. The Treasury now has 19 press offices and a further 17 who work for "Publishing and internal communications" and the "Correspondance and enquiry unit".
But the Treasury remains one of the leanest of the press offices. The Department of Health has 145 press officers and this does not include press officers for the Health Protection Agency, NHS Blood and Transplant, NHS Counter Fraud and Security Management Services or the NHS Institute for Innovation and Improvement and doubtless other agencies which are health-related.
There are about 197 full page listings in the booklet and, at a rough estimate, about 20 press officers per page (some room is needed to fit in their grand titles with words like 'head', ''chief', 'strategy' and 'senior' liberally sprinkled around). So that is about 3,940 press officers - and this is exclusively for national government. I wonder how many journalists are left in Fleet Street to ask them anything? It may be a staff-to-customers ratio that the Ritz would envy.
Essential reading for understanding how the NHS receives a lot of money from government but is always short of it for spending on healthcare.
There is a very similar story to be told in education, too.
Here is an article on the 'producer interest' with an interesting section on how those who are pursuing their interest use governments to further them, to the disadvantage of the public interest.
The expenses of MPs about which the public is expressing renewed anger were classic examples of the 'producer interest' in which employees in any organisation tend to start thinking of their own advantage to the disaadvantge of those they serve. (See previous posting.) When people can feather their nests, they often will. That is human nature unless there is a counteracting force such as the need to make a profit in a business, powerful peer pressure or a moral upbringing that would be unusual in modern Britain.
The worst of the nest-feathering, though, among MPs perhaps does not consist of the expenses. It consists of their pension arrangments.
It is the glaring contrast that makes one blink in disbelief. One the one hand, a child is dead who should have been saved. The department that should have saved her is described by Ofsted as “almost universally terrible”.
On the other hand, as if all this were totally irrelevant, the former head of the local authority department in question, Mrs Shoesmith, is described by her boss as a “heroine” and given a reward for her performance. She is only sacked after a public outcry. It is as if public servants lived in an Alice in Wonderland world of their own. Performance that looks disastrous in the real world looks terrific – no, ‘heroic” - in theirs.
When we first heard about the praise given so wholeheartedly to Mrs Shoesmith, our first reaction was probably to think, “How bizarre!” and write it off as an aberration. But it is not. It is just an extreme example of something as common as bills being paid late and men looking at pretty women.
I travel on the London tube occasionally and am always struck by an infuriating announcement that goes along the lines of “The Central Line is running thirty minutes late because of a signal failure at West Acton. The Northern Line is not operating currently and the Circle Line is subject to delays. Otherwise all lines are operating a good service.” [My italics.]
The self-congratulation is unattractive and absurd. They live in their own self-regarding bubble. Imagine you are in a Tesco supermarket and someone announces, “There is no milk today due to a delivery failure from Gloucestershire and there is no bread due to a getting-up-in-the-morning problem encountered by one of our staff. However we are offering a good service in baked beans and tinned prunes.” It never happens, does it? Why not?
Each of us will have our own idea but here is mine. When people work together in an organisation – any organisation – there is a tendency, over time, for them to think of how they can make their lives more comfortable. More money would be nice and really we could do with a tea break at eleven and a good, long lunch break would set us up for work in the afternoon. But we need to go at 3.45pm if at all possible to pick up the children from school. Oh and let us take it for granted that I will praise your work and you will praise mine.
In the private sector where there is competition, this tendency is usually counteracted sooner or later by one simple fact: if the company does not produce a really good service at a competitive price, it will go out of business. It is a question of “put the customer first or die”. And indeed some companies do die. The British-owned motor industry was more or less run for the convenience of the trade unions in the 1970s. They had their strikes and their so-called “industrial action” intended to stop the production line. The employees got their way for much of the time and, as a consequence, the motor bike industry, in particular, was destroyed.
Any famous company we know of today from Marks and Spencer to the Prudential could go bust if it does not keep down its costs, adapt to the times and keep giving customers “a good service”. And if it does really well, a company can expand, investing its profits and becoming an even bigger and more successful company, perhaps on the world stage. The same discipline simply does not apply in public service.
Oh yes, there are attempts to motivate people in a way that is just as good. Indeed there are some services that simply must be provided by government and so we have to find methods to motivate the managers and staff. But usually these methods are not as powerful or effective as those provided by the threat of competition and the lure of profits. Targets can even make things worse.
I am a governor of a state primary school and one of the strange things we have to do now and again is approve the ‘targets’ for the school in the SATS exams. These are targets which are based on the school’s previous results and on the nature of its intake and so on. It is all very complicated. The head and his staff spend time deciding what the targets should be, agreeing them with governors and with the local authority which, in turn, is acting under government guidelines. The game – not at my school, of course! – is for heads to set the targets as low as he or she can get away with and thus make it easily possible to meet the targets or triumphantly exceed them.
You will notice that amidst all this expenditure of cleverness and energy a) no child is actually being taught anything and b) the results tend to be manipulated and useless anyway. And at the end of the day, hundreds of schools up and down the country are congratulated on beating their targets utterly regardless of the fact that up to one in five children currently leaving British schools is barely literate. It is the same phenomenon again: real world failure accompanied by public servants congratulating each other.
The NHS is famous for its target times for patients waiting in accident and emergency and for treatment after a problem has been diagnosed. Some good is done in striving to achieve these targets and there is much self-congratulation by the government. But I well remember the bitterness of a surgeon who told me that the weekend before he had been instructed by the hospital manager to perform minor operations to meet targets while there were five or more people who had broken bones and were lying in hospital beds – urgent cases – which he was prevented from treating. That is what targets can do. And targets have not changed the fact that as many as 10,000 people a year die of cancer here who would not have done so if they had lived in an average European country.
Some people say, “I don’t care if I have a choice of hospital/school. I only care that a good one is available”. But that is to miss the vital element. The only reason that Tesco provides a good service is because you could go to Waitrose, Asda, Marks and Spencer, Morrison’s or Sainsbury’s. Yes, there are some good state schools. I have observed superb classes in one. And there are some heroic nurses and doctors. My admiration for the expertise and work rate of one staff nurse who cared for my mother is boundless.
There is such a thing as people working philanthropically and because they want to do good. There is such a thing as people taking pride in their work, whatever it is. Both apply, incidentally, to the private as well as the public sector – not to mention the charities.
But as a generalisation, the overwhelming truth remains: there is a tendency in human nature for people to try to make their working conditions as comfortable as possible, often to the disadvantage of those they are meant to serve. And in the public sector, performance targets are not good enough to counteract it and are often totally removed from the experience of those the service affects. And that, I am afraid, is how we get to the grotesque congratulations for Mrs Shoesmith.
Those who find the constant drip of anti-capitalism from most of the presenters on the BBC Radio 4 'Today programme' aggravating now have a more bearable alternative: Radio 5 Live, despite also coming from the BBC, generally has more open-minded presenters. Nicky Campbell is certainly not anti-capitalist and is able to ask questions which seem wholly beyond John Humphrys and Jim Naughtie on the Today Programme. True, there is a certain Left-wing bias to the questions of a chap called Bacon, but he is not usually around in the morning, I think.
Despite all the evidence, I still hope that one day the Today Programme might reform. In case the producers finally decide that the interviewers should sometimes ask questions from a free market viewpoint instead of always a Left-of-centre one, I offer some suggestions:
TO BE PUT OVER THE MIRRORS OF JOHN HUMPHRYS AND JIM NAUGHTIE
"Wouldn't this problem best be left to the market?"
"Government service + monopoly = bureaucracy + bad service + rationing. Which part of that do you disagree with, minister?"
"Since this government service has done so badly, does it make sense to throw more taxpayer's money at it?"
"Is it responsible to raise taxes when you know - or should know - that all taxes have bad unintended consequences?"
"We know what all this extra public spending will lead to don't we, minister: more waste of taxpayer's money, more index-linked pensions and early retirements, less productivity..."
"The government already taxes people whom it defines as being 'in poverty'. Is it morally right to add to those taxes?"
And here is a long one, especially for Jim:
"Since the government already taxes poor, elderly people, any further spending by government has to face a severe test: it has got to be more worthwhile than reducing the taxation of the poor. Your idea [for letting off fireworks/keeping an out-of-date car factory going etc etc] does not pass this test, does it minister?"
Further suggestions welcome.
Here is a pretty good answer. It is by John Steele Gordon in the Wall Street Journal on May 21st. (I have edited it a bit. The full article is here.)
1) Governments are run by politicians, not businessmen. ... Because of the need to be re-elected, politicians are always likely to have a short-term bias. What looks good right now is more important to politicians than long-term consequences even when those consequences can be easily foreseen. The gathering disaster of Social Security has been obvious for years, but politics has prevented needed reforms.
And politicians tend to favor parochial interests over sound economic sense.
2) Politicians need headlines. And this means they have a deep need to do something ("Sen. Snoot Moves on Widget Crisis!"), even when doing nothing would be the better option. Markets will always deal efficiently with gluts and shortages, but letting the market work doesn't produce favorable headlines and, indeed, often produces the opposite ("Sen. Snoot Fails to Move on Widget Crisis!").
3) Governments use other people's money. Corporations play with their own money.
So a labor negotiation in a corporation is a negotiation over how to divide the wealth that is created between stockholders and workers. Each side knows that if they drive too hard a bargain they risk killing the goose that lays golden eggs for both sides.
But when, say, a school board sits down to negotiate with a teachers union or decide how many administrators are needed, the goose is the taxpayer. That's why public-service employees now often have much more generous benefits than their private-sector counterparts. And that's why the New York City public school system had an administrator-to-student ratio 10 times as high as the city's Catholic school system, at least until Mayor Michael Bloomberg (a more than competent businessman before he entered politics) took charge of the system.
4) Government does not tolerate competition. The Obama administration is talking about creating a "public option" that would compete in the health-insurance marketplace with profit-seeking companies. But has a government entity ever competed successfully on a level playing field with private companies? I don't know of one.
5) Government enterprises are almost always monopolies and thus do not face competition at all. But competition is exactly what makes capitalism so successful an economic system. The lack of it has always doomed socialist economies.
When the federal government nationalized the phone system in 1917, justifying it as a wartime measure that would lower costs, it turned it over to the Post Office to run. (The process was called "postalization," a word that should send shivers down the back of any believer in free markets.) But despite the promise of lower prices, practically the first thing the Post Office did when it took over was . . . raise prices.
Cost cutting is alien to the culture of all bureaucracies. Indeed, when cost cutting is inescapable, bureaucracies often make cuts that will produce maximum public inconvenience, generating political pressure to reverse the cuts.
6) Successful corporations are run by benevolent despots. The CEO of a corporation has the power to manage effectively. He decides company policy, organizes the corporate structure, and allocates resources pretty much as he thinks best. The board of directors ordinarily does nothing more than ratify his moves (or, of course, fire him). This allows a company to act quickly when needed.
But American government was designed by the Founding Fathers to be inefficient, and inefficient it most certainly is. The president is the government's CEO, but except for trivial matters he can't do anything without the permission of two separate, very large committees (the House and Senate) whose members have their own political agendas. Government always has many cooks, which is why the government's broth is so often spoiled.
7) Government is regulated by government. When "postalization" of the nation's phone system appeared imminent in 1917, Theodore Vail, the president of AT&T, admitted that his company was, effectively, a monopoly. But he noted that "all monopolies should be regulated. Government ownership would be an unregulated monopoly."
It is government's job to make and enforce the rules that allow a civilized society to flourish. But it has a dismal record of regulating itself.
Capitalism isn't perfect. Indeed, to paraphrase Winston Churchill's famous description of democracy, it's the worst economic system except for all the others. But the inescapable fact is that only the profit motive and competition keep enterprises lean, efficient, innovative and customer-oriented.
One of the concepts that is vitally important to understanding why government services tend to develop low productivity is "the producer interest" - the tendency of those who provide a service to start thinking as much or more about their own interests as they do about their customers.
This is a concept that politicians themselves have had a tendency to brush aside. "Of course, doctors/nurses/policemen/teachers are far too decent and well-intentioned to behave like that," they say as if nobly defending the honour of individuals who have been unjustly slurred. Well, they can't pretend they don't understand the concept now. The politicians themselves have been found manipulating their expenses system to pay for the cleaning of their moats, the refurbishment of their houses and so on and on. They milked the system for their own benefit. The Daily Telegraph has been full of the gory details for the past five days or so. We paid more for our MPs than we realised. Their productivity was lower per pound. Money was wasted.
So my question is this: why do Members of Parliament expect doctors, nurses, policemen and teachers to be more upright, moral and public spirited than they are themselves?
A few days ago, I met a consultant who told me patient care has become worse in the past five years. She mentioned a number of things that were worrying and/or were making the business of treating patients more difficult.
1. The NHS management has imposed an expectation that, in her speciality, there should be two follow-up meetings with patients for every one meeting with a new patient. This target varies from one speciality to another. Her target is, as far as she is concerned, wholly arbitrary and damaging to good patient care. She believes that good care requires, on average, a higher proportion of follow-ups. But if the hospital fails to keep to the proportion prescribed, then it will lose some funding. So an attempt must be made to keep to it or to fake it.
If they were to keep to it, then patients who needed to be seen more than twice after the initial visit would suffer. She suggested that therefore, in order to maintain good patient care despite the target, they fake it - at least some of the time. They call an old patient a new patient. Presumably they pretend that the patient has a new ailment whereas, in fact, it is the continuation of the old one.
How depressing it is that senior doctors have to spend their time getting around silly rules rather than devoting themselves to their job of looking after patients.
2. She told me that doctors gain the status of consultants far more quickly than before. Previously they spent four years training generally and then another seven years in their speciality. They also worked all hours, thereby seeing a great deal of illnesses and their treatment. Now, however, they can be called 'consultants' after only five or six years and they have had significantly less experience in those years than they would have done previously because of the new rules limiting their working hours. A consultant today is often not the highly experienced top doctor that he or she would have necessarily been in the past.
3. Another effect of the new working hours is that the new consultants more frequently than before have a shift mentality. When their time is up, they go home regardless of the state of their patients. This is a change from the time when a consultant very frequently felt his or her prime responsibility was to the patient and that this would quite often mean he or she would stay around until a procedure involving the patient was complete.
4. She told me that there is a drive for doctors to account for everything thing they do. She said that in one hospital, I think it might have been Great Ormonde's in London, they were trying out a system whereby doctors would account for each thing they did for patients on a personal digital assistant (PDA. I remarked that I had recently seen another consultant in a different hospital swiftly moving from task to task - ordering an X-ray for one patient, asking for another patient to go to his office, consulting with another doctor about a third patient, examining the second patient, looking at X-rays for a fourth patient, having a word with the relatives of that patient all in quick succession. If he had had to itemise such things, he would not have had time to do them. She heartily agreed. In trying to monitor such things, the administrators were going to damage the productivity of doctors and thus damage patient care.
5. She also remarked what a vast army of people there must be doing all the monitoring of targets. Somebody from her hospital would have to collate all the figures showing whether or not she was meeting the unnecessary and damaging target of two follow-up consultations for every one initial consultation. Then the information would have to be sent to the central administrators who would have to check and analyse the figures. I presume someone would have to decide if the funding should be cut. Letters and warnings would be issued and replied to. Someone must also have been paid who thought up the idea. Someone must have thought up how it should be implemented. Stationery would have been designed, printed and distributed to hospitals. And so on and on. One bad 'bright' idea. Hundreds more people employed by the NHS to produce no improvement in treatment. In fact their employment damages patient treatment since their wages and costs such as office space, heating, lighting, pension rights and so on have to be taken out of the NHS budget and taken away from patient care.
I had spoken to this consultant when researching The Welfare State We're In. She told me that she thought things in the NHS were bad then but they are worse now. She also remarked that having damaged the NHS, the regulators and administrators have also moved in on the private sector, requiring more and causing more damage even to the private sector.
6. There is a requirement now that hospital consultants can only do certain treatments if the hospital concerned has beds that are suitable for that particular speciality. Presumably this is in case there is a mishap and the patient needs a hospital bed. But the result is that hospitals where a consultant used to do minor treatments immediately and on the spot are not allowed to do this any more. In the past, the consultant could decide whether or not it was wise to do such treatments. Now he or she is not allowed to decide. The patient has to make a new appointment at a different hospital, quite possibly seeing a different consultant who has to learn about the case afresh. Patient time and care is damaged. More consultant time is wasted.
She painted a very depressing picture of how the NHS is being administered and how even the private sector is being interfered with and damaged by government.
The simple point about the NHS computer fiasco is this: that governments repeatedly botch up major projects. The result is that huge amounts of money that could have been spent on patient care has been wasted.
Why do governments keep on wasting money on this spectacular scale? Because no one is truly both a) in charge and b) accountable. When Marks and Spencer was adrift and losing market share, the chief executive and many others got the sack and their reputations were damaged. No one has publicly got the sack for this vast waste of public money.
Here are some of the details as described by Richard Bacon M.P. in the Daily Telegraph today:
By now, almost every hospital in England is supposed to have key administrative software deployed as the essential first step in introducing the shiny new electronic patient record. They are miles behind schedule, yet the limited deployment has already caused havoc, with significant delays in providing inoculations to children, waiting list breaches, missing patient records and the inability to report activity statistics. Not to mention the trifling matter of the largest computer crash in NHS history, when 80 hospitals had no access to patient administration systems for four days.
This is a truly grim tale. More than £2 billion has been spent, and although there is no detailed record of overall expenditure on the programme, estimates of its total cost have ranged from £6.2 billion up to £20 billion. There have been six bosses in five years. Timetables are fictitious and the programme is now years behind.
Doctors, nurses and hospital managers have been left spitting with rage. Most GPs think the appointment booking system is a joke. And three fifths of the programme is dependent on a software supplier called iSoft, which is currently under investigation by the Financial Services Authority and whose flagship software product, "Lorenzo", does not exist yet (even though the company said it was available three years ago). In the meantime, iSoft has been merrily selling old software that pre-dates the national programme.
Today, Parliament's spending watchdog publishes a report on this multi-billion-pound fiasco, which concludes: "At the present rate of progress, it is unlikely that significant clinical benefits will be delivered by the end of the contract period." The whole project has been an object lesson in how not do it.
The full article is here.
The news story is here.
Some people say, "Ah yes, governments may well waste money. But so does the private sector."
Of course this is true. There is waste in every kind of organisation. The key issue, though, is how much?
When it comes to employing more people than necessary to do a job, the public sector is in a different league compared to the private sector.
The old Central Electricity Generating Board used to employ 26,000 people. All of them, it would have been claimed at the time, were necessary to the production of electricity.
Five years after privatisation of the board, the two companies which the CEGB was turned into - National Power and Powergen - employed few than 9,000 people.
Electricity continued to be generated.
I am grateful to Colin Robinson for these figures.
Just think how many thousands of people, that poor people pay for through their taxes, are currently employed - but not actually necessary for the job to be done - in the NHS and in education today.
In the wake of the budget, I will be taking part in a lunchtime debate tomorrow (Thursday) on the subject: "Does public spending gives us enough bang for our buck?". It will come no surprise to those who have read 'The Welfare State We're In' that I will argue that public spending tends to be extremely wasteful.
The debate will take take place at the Royal Society for the Encouragement of the Arts. (I am sorry to be disrespectful to the hosts of this debate, but I notice that the RSA appears to be another ancient charity whose original purpose is no longer respected. I rather doubt that the 18th century creators of the society would have subscribed to its current commitment towards creating a 'zero-waste society'. It is quite a modern racket, this taking over old charities and using the money to get an income and promote one's views.)
For a variety of entries on 'waste in public services', try this category in the list in the left-hand column.
One of the contentions of The Welfare State We're In is that the welfare state has been a major contributor to the massive rise in crime and anti-social behaviour since the beginning of the 20th century. The problem is compounded by the fact that the state, in addition to being a bad supplier of welfare, tends to be a bad administrator of everything else it does, too. This applies to all aspects of criminal justice including investigation of crimes, prosecution, the courts and punishment.
The poor performance of the state in these areas exacerbates the increased crime for which the welfare state is largely responsible.
At the end of last month, Lord Ramsbotham, the former prisons chief, wrote a scathing attack on the administration of prisons in The Independent. It was significant because it came from such a well-placed soure.
This is part of what he wrote:
Yesterday's announcement that the prison population now exceeds 80,000 is the latest low point in what one can only describe as the Government's headlong and self-induced race to absurdity as far as the conduct of imprisonment is concerned.
He cites various reasons for this. The one that is particularly worrying is this:
If you do not resource prisons, to enable them to conduct work, education and training, prisoners are more likely to reoffend, as proved by the fact that the reoffending rate among adult males has gone up from 55 per cent to 67 per cent in the past five years.
That rise in re-offending seems remarkable and suggests, all by itself, that something may be going badly wrong in our prisons.
What could it be?
He offers various explanations but I am particularly struck by his mention of this:
The probation services are overstretched - there are 300 fewer officers and 1,500 more bureaucrats than five years ago.
It seems there is no part of the administration of the state which has not become more and more dominated by bureaucracy and administration rather than people actually doing the job. I apologise for repeating in many ways that the state has an inbuilt tendency to become inefficient but the point is vital and so little understood and accepted.
The full article is here.
A good article by Tom Stevenson about the amazing rise and rise of red tape. It matters because resources and efforts are wasted. We would be richer and freer with less government. The poor could do with the money and the rich could do with the freedom.
From John Clare's column in the Daily Telegraph yesterday:
My son, who has just turned 16, is being urged by his school to sign up for a "Connexions Card". What's it all about?
Another Government black hole. More than a million cards have been issued over the past five years supposedly to encourage youngsters aged 16 to 19 to "keep learning". Holders collect "reward points" for turning up at school or college and then "spend" them on CDs, DVDs, mobile phone accessories or whatever the scheme's commercial sponsors are peddling.
As harmless - and pointless - as a supermarket "loyalty card", you might think. But so far, issuing the cards - which contain a chip storing the holder's personal details - has cost taxpayers £72 million, of which £66 million has gone to Capita, the Government's favourite private-sector dog'sbody.
What proof is there of any educational benefit? "There is no evidence that the originally intended impact on increasing post-16 participation in further education and training is yet being achieved" - Beverley Hughes, a junior minister in the Department for Education (with commendable honesty). Capita, however, has been told to carry on churning out the cards, for which it will be paid another £40 million between now and December 2008. Isn't it fun wasting other people's money?
I am sorry to quote the Daily Mail for a third time in one day. Why on earth does not every newspaper carry this story?
Scores of newly-qualified consultants are stuck without jobs because of mounting NHS debts, Britain's most senior surgeon has warned.
Bernard Ribeiro, president of the Royal College of Surgeons, said the predicted £1 billion deficit in the NHS has led to a 'vacancy freeze' for doctors who have passed their consultant exams.
This means dozens of trainee consultants are now facing unemployment or are considering retraining.
It amounts to a huge waste of taxpayers' money given that it costs £237,000 to get just one student through medical school.
Each of these new consultants has also had up to 12 years training within the NHS to reach consultant level.
Figures from specialist associations within the college suggest there are 37 cardiac surgeons, 12 neurosurgeons and 35 ear, nose and throat specialists, who are all qualified to be consultants but have not got a job.
Mr Ribeiro said: 'Trusts are not employing new surgeons because simply the money is not there.
'All have their certificate, all are available for a job and there are no jobs for them.'
The full story is here.
It is a truth, insufficiently acknowledged, that whenever the central government organises something, it wastes money and people. The cost is borne by taxpayers who, these days, include many who are relatively poor. It therefore follows that the process of having the government organise things is automatically to cause the relatively poor to be taxed more heavily.
The most extreme, single demonstration of the waste perpetrated by government is the computerisation of the NHS. The whole appallingly wasteful exercise, costing billions of pounds to taxpayers, appears to have started with the wholly ignorant, amateur idea of one politician: Mr Tony Blair.
Here, from the Sunday Telegraph yesterday, is an account of how he made this very important decision and how effective the actions he started have been:
Elated by the prospect of prescriptions pinging into patients' e-mail accounts, of ridding surgeries of yellowing records and A&E departments of carbon paper, Mr Blair, according to one observer, had "a Tony moment". With a wave of his hand, he gave the go-ahead for the biggest public sector IT project the world has seen - a scheme which has now become one of the biggest IT turkeys the world has seen.
The plan would link more than 30,000 GPs with 300 hospitals. "Up to 600 million pieces of paper a year" would be saved, Mr Blair promised. Patients' notes would be available in any hospital at the click of a mouse, and GPs would be able to book hospital appointments over the internet ("choose and book"). The Prime Minister even joked about making GPs' handwriting "legible for the first time in history".
Four years later, the joke is on Mr Blair, and the taxpayer. The "Connecting for Health" project is two years behind schedule and more than three times over its initial £6.2 billion budget. Lord Warner, the health minister, revealed this week that the real cost of the programme would approach £20 billion by 2010, its revised delivery date.
A report by the National Audit Office (NAO) is expected to be damning, suggesting that corners were cut so that political deadlines could be met. More than £11.75 million of taxpayers' money has been lavished on consultants, including Ernst & Young, Price Waterhouse Coopers, PA Consulting, Cap Gemini and IBM.
Yet the glitzy, "joined-up" NHS remains a low-tech hotch-potch. Doctors are largely unimpressed. Dr Richard Vautrey, a GP in Leeds and spokesman for the British Medical Association on IT, has struggled for months, for example, to get "choose and book" working.
It should enable GPs to offer patients a choice of four hospitals but has been beset by technical difficulties. "It does work in some places, but we haven't been able to get it to," says Dr Vautrey.
Certain hospitals, mindful of waiting-time targets, are also refusing to make appointments available.
With its 950-strong staff and an annual wage bill of about £50million, Connecting for Health does not lack resources. Still, it has become the latest in a series of public sector IT fiascos which include the Passport Office, Air Traffic Control, the Child Support Agency and the Inland Revenue.
See also the accompanying article which begins:
It is very unclear how the NHS is going to find the money to pay for the National Programme for IT. A project that was supposed to cost £5billion and last less than three years is now due to cost £20billion and last at least a decade.
Gordon Brown would like to send taxpayers' money to provide more education in Africa, by which he means more state education. There are far better ways of helping Africa. Below is part of an article in yesterday's Sunday Telegraph. It graphically describes how money put into state education in Pakistan has been wasted on an astonishing scale.
Of course Africa is not Pakistan. But it is hardly renowned as a place where government corruption is unknown. And James Tooley's Newsnight report from Africa last year indicated that, on the contrary, money spent on state education in certain countries there was by no means well spent.
If poor people in Britain were taxed in order to hand over their money to African government to waste in anything like the way described below, it would be appalling.
Millions of children in Pakistan are denied even a basic education because of wide-scale corruption and inefficiency in the state system, an independent watchdog has revealed.
At one school, the playground is so full of rubbish dumped by neighbours that the stench is too foul for children to play, in another, the classrooms are used to store grain and at a third, 49 teachers draw salaries even though there are no pupils.
Yet a report by the Human Rights Commission of Pakistan claims that such cases are far from unusual, and that state education is so crippled by graft and its accounts so poorly monitored, that millions of pupils are receiving no meaningful education. About 40,000 "ghost schools" stand empty or are used for other purposes.
Of the often-squalid, crowded schools where teachers and pupils do actually meet, more than 60,000 (39 per cent) have no drinking water, 96,000 (62 per cent) have no electricity and 76,000 (49 per cent) have no lavatories, the report, published last month, reveals.
At Karachi's Haqqani Chowk School, 49 teachers are on the payroll, costing the school £7,170 a month, but no pupils are registered. At another primary school in the city, 40 teachers have been appointed to teach only 11 enrolled children.
"Most of the teachers in public-sector schools have secured postings to institutions where they need not attend every day, and at least 50 per cent of the teaching staff in public-sector schools are 'ghost teachers'," said Abdul Wahab Abbassi, a senior education official.
The absentee teachers handed between 30 and 40 per cent of their salaries to district education supervisors to ensure that they kept their "jobs", Mr Abbassi added.
In Sindh province, of which Karachi is the capital, 3,228 school buildings are used as autaqs - gathering places for men - or for grain storage, and their playgrounds as livestock pens.
The reason why so much new money has done relatively little for the quality of the NHS is that so much has been wasted. This is part and parcel of how state monopoly services tend to operate.
One of the ways in which money has been wasted in the NHS appears to be in paying GPs more than is necessary to retain their services. Of course it is also true that the NHS has increased the amoung of money that is necessary to retain their services by making the job less satisfying and more bureaucratic. So there has been a double-whammy of extra cost.
This is from a good article in the Sunday Telegraph detailing quite a few examples of waste in the NHS:
There is no doubt that GPs have been the biggest winners of the boom in NHS spending, which has increased by £22 billion over the past four years. In 2003/04, the last year before GPs were put on to new performance-related contracts, they worked according to a contract that gave them an intended annual income of £61,000.
This year, admits the BMA, GPs are taking home an average of £94,000 a year, making them the best-paid in the world outside the United States. Moreover, many have simultaneously managed to cut their workload dramatically. Until 2004, GPs were responsible for 24-hour care of their patients. They didn't have to be on call at night, but if they opted out they were obliged to provide cover out of their own pockets.
Under the new contracts, by contrast, GPs can opt out of being on call at weekends and during evenings by giving up just £6,000 a year of their pay. But they can quite easily more than make up for this in other ways. GPs are now paid on a points system called the Quality and Outcomes Framework. Points, each worth £125 a year, can be earned, for example, by monitoring diseases and providing advice.
For example, GPs can earn an annual bonus of £8,472 if they record whether patients with heart disease or asthma are smokers and offer them advice on giving up smoking. Compiling a register of diabetics, taking their blood pressure and treating their symptoms can earn a GP a further bonus of up to £11,587.
"The system was predicated on the basis that GPs would get 700 or 800 points," says Dr James Le Fanu, a GP for 20 years. "But it quickly became clear that it was not very difficult to start getting 1,000 points a year, which is where salaries of £125,000 a year come from. What's more, GPs are earning this extra money for doing things that they should have been, and most were, doing anyway. Paying GPs to meet targets is a very bureaucratic view of what the health service should be about. Being a GP is not just about measuring blood pressure. It is about sitting down with people and talking to them."
Richard Charkin, a publisher, has a blog and this is part of an entry from it about Tim Coates, the former managing director of the bookshop Waterstones:
He is currently involved in a highly personal campaign to encourage the British Government and local authorities to spend library budgets on books - a simple, obvious but difficult objective. Not everyone agrees with Tim's in-your-face approach to campaigning but at the very least he has made the topic unignorable. I asked him to write a guest blog for me and here it is:
"Half the management in this country is public sector. The rules are different: income does not depend on judgment, efficiency or perfomance; cash is available; there is no such thing as bankruptcy and nor are there the disciplines, anxieties, skills and systems which are used to avoid it. Employment is secure and very well paid. Projects thrive on persuasive plans but rarely on actual outcomes. To a private sector manager, the regime is unfamiliar.
We have become used to the idea that only a small portion of charitable donations reach their intended recipients; we should get used to the idea that the great part of the money we thought was for public service will never reach any public beneficiary. We live in an economy which is the travelling equivalent of a crowded roundabout. Huge amounts of public funds travel on a journey which goes nowhere in an unpleasant and wasteful manner.
The full entry is here.
Incidentally, publishing is dominated by people who are left-wing and therefore, implicitly, believe that government is the answer to most problems. It is refreshing to see a few publishers who are open to the idea that, in fact, governments tend to be incompetent and wasteful. It would be good to have a bit more detail of the waste that Mr Coates has come across.
"There are only two types of money: your own money and other people's money."
From a well-made article about how governments tend to waste money. It is by Ian Cowie in today's Telegraph.
We are regularly told in Britain that water is vital to the health of many millions of people in Africa and elsewhere. So it is. But never is it suggested that the reason there is such a problem with water in Africa is because water supply is run by governments, not private companies. That would be to undermine the 'government is best' assumption of virtually all broadcast media coverage in Britain.
Now, at last, comes a paper from the Globalization Institute putting the argument that millions of people in Africa have died because of this misguided belief that government is best.
These are the opening lines of the paper, by Mischa Balen, apparently a Labour Party activist:
Over a billion people worldwide do not have access to safe drinking water, and 2.6 billion people have no sanitation facilities. More than two million people die each year from diarrhoea, and over six million people are blind as a result of trachoma, a disease strongly related to lack of face washing. In Sub Saharan Africa, 42% of the population lacks access to decent water.
Other diseases which are caused by water poverty include scabies, typhoid and malaria. The need for clean water to prevent the spread of these and other diseases is therefore paramount.
This is one of the greatest problems humanity faces. It is a problem which is taking place under the auspices of the state sector: 95% of the world's population gets its water from state-run services. Government provision in water has overseen millions of deaths through poor quality and lack of sanitation.
Balen goes on to argue that access to clean water has increased significantly in those countries which have allowed some privatisation. (He is virtually always talking about government-regulated privatisation, incidentally. It would be interesting to know if there have been any complete privatisations, without heavy government controls, and how well these have improved supply.)
In Tunja, Colombia, access to water increased by 10% folllowing privatision; in Gabon the figure was almost 15%. Cartagena, Colombia posted access increases of 25%, Conakry, Guinea of 20% and La Paz - El Alto, Bolivia of 10%. In Chile, 99% of urban residents, as well as 94% of rural residents are now supplied with water all day round, which contrasts fabourably with pre-privatisation figures of 63% and 27% respectively. Finally, Corrientes, Argentina, and Cote d'Ivoire saw increases of almost 15%.
He makes the point that a private company only makes any money if a water connection is sucessfully made. Meanwhile an employee of a state industry goes on getting paid regardless of how many connections are made.
Private companies are also less wasteful. Money is spent replacing leaking pipes, for example.
Under public ownership, the amount of water leaked from Buenos Aires's system as a percentage of the total water available was 45%. Now just 0.18 metres cubed per connection per day is lost.
There are fewer unnecessary workers employed, too, which reduces the cost of supply water and thus increases its affordability.
In Chile, the private sector managed to reduce its workforce by 30% during 1998 to 2001, a period which saw public sector employment fall by just 5%. This was achieved alongside an increase in the customer base of 6%.
The website of the Globalization Institute is here.
A fascinating assertion by Frank Field MP is reported in the Guardian. It is that many thousands of claimants are not medically examined as they should be. They are therefore given incapacity benefit when doctors think most of them should not receive the benefit.
Why are they not examined? It seems, if I understand correctly, that it is because there is a budget for the examinations and once that budget is used up, the administrators discourage General Practitioners from referring any more claimants for further medical examination. This sounds like monstrous incompetence and maladministration.
This is from the Guardian article:
Mr Field challenged claims that the government was successfully monitoring the IB process, and said the contract with Schlumberger Medical Services, the firm responsible for conducting incapacity tests, needed renegotiation.
He wrote: "Doctors inform me that if they were allowed to use their own judgment, they would indicate that between 65 and 75% of files they examine should be followed by a medical examination". Doctors report they are told however by medical quality managers (their line managers) that "the service will not be able to meet its target and - therefore incur financial penalties - without reducing the number of clients examined."
He said local benefit offices "are constrained by a quota on the number of IB files that can be referred to the government's medical services for scrutiny. They cannot refer every file they would wish".
He pointed out that the doctors employed by Schlumberger on behalf of DWP "work off a quota and once they fulfil their quota, it is held over for the next month's quota. Very quickly the backlog develops."
The full article is here.
Not long ago, someone commented on this site that whenever all or part of the NHS runs out of money, wards are closed or operations are delayed or some other cost-saving measure is taken. But never are salaries cut back.
The fact illustrates the way in which government-provided services, as opposed to commercial or charitable ones, have a particularly strong tendency to look after their staff first, rather than the customers (or patients or students) who receive the service. Of course it does not feel like that to the doctors, nurses, administrators, teachers and so on. It feels to them like they are badly paid and enduring difficult and frustrating conditions. This is often true, too. But the fact remains that their pay and pensions are kept sacrosanct that would not apply if they were in the commercial or charitable world.
Further evidence of this came at the weekend in this story:
Studies of the proportion of council tax used to fund pensions are usually restricted to contributions that go solely to the pension funds of local authority staff.
But Mr Anderson discovered the hidden cost to council tax payers was much greater - when the money used to fund centrally administered "pay as you go" schemes benefiting the police, firefighters and teachers was added.
"We calculate some 26 per cent of council tax receipts go towards public sector pensions. There's every possibility this figure will rise over the next five years as age-related costs continue to feed in."
Such is Mr Anderson's expertise that he is regularly called in to advise Government departments on pensions. His calculations were based on a trawl through the books of 16 county councils.
The full story from the Sunday Telegraph is here.
Another step forward: a six-part BBC series on benefits and how they got wrong. The first one, tonight, appears to be about benefit fraud. According the Telegraph,
David Street, the series' producer, said: "These are just a few of the cases that are prosecuted every year. The scale of fraud in disability living allowance claims is just staggering.
"I have made a lot of programmes about fraud and I have to say I was stunned by the size of this problem."
The full article is here.
The programme is on BBC1 at 8.30pm tonight and is called 'On the fiddle'.
The inefficiency of state welfare is shocking and mostly unreported. As newspapers cut their staff ever more, they are all the more dependent on Government announcements. But now and again, in place of the propaganda, we get insights into what is really going on. This story tells directly of large-scale incompetence of the state in administering welfare. Such a thing would result in legal action and possibly bankruptcy for a commercial company or a mutual society such as the Equitable. What the story does not describe is the human distress caused to those at the receiving end. One can imagine people in genuine need and already in a bad way being thoroughly depressed by this maladministration:
One million calls from jobless people seeking their first benefit payment have gone unanswered because of teething problems with a computerised call centre system, according to confidential Department for Work and Pensions documents.
People have to wait for up to six weeks to get benefits because processing centres cannot keep up with the workload. The delays follow cuts in staffing as part of the government's decision to scrap 80,000 civil service jobs over three years.
The worst-performing centres are in Sheffield, Hastings, Coventry and Poole, where more than half of calls are never answered. Even the best performing centres in Blackburn, Paisley and Grimsby, fail to answer one in five calls.
Figures collected by senior managers for Jobcentre Plus show how many calls have been made and answered since introduction of a new call centre and IT system earlier this year. The DWP has already shed 14,215 staff, making it the lead department in Whitehall for job cuts.
Under the changes the agency has stopped handling most benefit claims at local offices and now tells people to ring call centres, who then pass their claim to processing centres. As a result MPs and citizens' advice bureaux are being deluged with complaints.
Labour MP Anthony Wright told MPs: "In Suffolk, only three of the 13 sites take claims ... Soon, people from North Walsham [in Norfolk] will be required to choose to attend one of three sites, necessitating an up to 50-mile round trip."
This version of the story was in the Guardian.
I was invited to appear on Radio 5 Live last night in a discussion about the decision of the NHS in East Suffolk that GPs and consultants will not refer anyone classed as obese for hip and knee replacements.
I argued that this level of rationing of healthcare was the inevitable result of having the NHS which, like most state monopolies, wastes its money and staff on an enormous scale. I referred to the study by Maurice Slevin which indicated that the managerial, administrative and support staff in the NHS per nurse runs at four times the level of a private hospital. In the NHS there are eight management, admin and support staff per ten nurses compared to only 1.8 in a private hospital.
Unfortunately I did not have the opportunity to counter an argument put forward by Roy Lilley (please excuse me if I have mispelled his name) a former NHS Trust chairman. He asserted that only 2.8 per cent of the staff in the NHS were senior management.
That is the sort of statistic that the NHS loves to trot out on such occasions. It gives the impression that there is no overmanning. But that impression is utterly misleading.
One needs to note the precise phrase being used. He did not say 'Management, administrative and support staff' he defined it very narrowly by saying 'senior management'. That really does not address the argument at all. The assertion is that the NHS is inefficient and wasteful in its employment of all these managerial and back-up staff as a whole - not that it is merely wasteful with the numbers of 'senior management'.
Incidentally, I don't know how the word 'senior' is defined. But it is obviously very easy to define that word as one likes. If one defines it very narrowly, then even this figure could indicate wasteful use of resources. Think of this parallel: if one said, 'only 2.8 per cent of the employees of the army are generals' it would indicate massive over-employment of generals.
The audience of parents of children at Tonbridge School last night was one of the most positive and supportive I have come across.
I talked mainly about how the welfare state has damaged the culture and morality of Britain and how it has led to higher levels of crime. One member of the audience responded by saying he had been a fireman who had worked in council estates. There had been youths there who he described as 'untouchables' - that is they were not touched or cowed by anything. They did not care if they were arrested, or got hurt or went to prison. These youths would throw bricks at himself and other firemen as they tried to put out fires.
What an extraordinary level of alienation for society must have taken place for people to throw bricks at firemen. It is staggering and shocking. It is also, surely, something similar to the alienation of the French youths rioting in French towns at present.
A hospital consultant made the comment that he saw a proliferation of administrative or managerial non-jobs in hospitals - people involved in diversity or equality promotion.
Someone else suggested there was a great deal of over-qualification going on in the NHS. This applied not only to nurses but also to physiotherapists and all sorts of others.
Another woman expressed outrage and disgust that people with ordinary incomes, who were saving for their families, were now due to get hit with inheritance tax which would go to give money to young girls having babies out of wedlock. It was interesting to come across that kind of raw anger and sense of injustice. In The Welfare State We're In, I tried to avoid a tone of anger. I tried to keep as much as possible to the observable damage the welfare state has done to the whole of society, especially the poor. But the woman's anger is perfectly understandable and justified.
The working poor are now taxed quite heavily. For people to be angry at the misuse of taxpayers' money can no longer be described as merely the rich moaning about being made to give money to the poor. It is everyone showing a justifiable opposition to money being taken from the working and decent and spent on encouraging and subsidising others not to work or to behave in other ways which are damaging to themselves and others.
It is often quite difficult to get at the convincing detail of how the state is a bad provider of services such as schooling and healthcare. Most people simply do not see the waste, inefficiency and organised morale-sapping in action and so do not believe they all exist. Here, though, is one example culled from the excellent 'Any questions?" column by John Clare in Saturday's Daily Telegraph.
The question asked is:
What is the "endless paperwork" teachers are always complaining about?
It varies from school to school because heads interpret the centrally imposed requirements differently. It also depends on the stage of a teacher's career. For recently qualified teachers, the biggest burden can be having to write a detailed plan of every lesson they teach, carefully differentiated according to the needs of able, average and less able pupils, as well as the "gifted and talented", those who have special needs or speak English as an additional language. In some schools, that can run to 2,000 words a day.
The heaviest load is carried by heads of department, who are responsible for the elaborate self-evaluation forms that Ofsted inspectors now demand. Most time-consuming for rank-and-file teachers is the regular - often fortnightly - grading of every pupil, the form-filling generated by every disciplinary action they take and - most controversially - the innocent-sounding "helping pupils with their coursework", which can involve extensive (but illegal) rewriting of lengthy essays. Every teacher could add to the list and most of it is time taken away from teaching.
All sorts of cutbacks are currently taking place in NHS services. These are not announced, of course. Newspapers and the rest of us find out or just hear about them incidentally.
Yesterday an osteopath told me that because of a £30 million deficit in the accounts of the Kensington and Chelsea Primary Care Trust, osteopathy services had been cut. She said that the introduction of osteopathy had cut the waiting list for physiotherapy services from 20 weeks to 6 weeks. It had prevented many people developing chronic muskulo-skeletal problems. They had been caught in time. Now they would not be.
A few months ago a physiotherapist in Hampshire told me of cuts in physiotherapy there. She was in despair at what was happening. These are just straws in the wind to add to what is in the public domain. A survey by the BMA last month found 385 of the 530 primary care and other trusts had deficits totalling £2.4billion. St George's Healthcare Trust in London is losing 60 beds, trying to reduce a £24.5million overspend. It is truly remarkable that at a time when far more is being spent on the NHS that such cuts should be occurring. Even I - convinced as I am that there is huge waste in the NHS and that state monopolies have a strong tendency to be incompetent and wasteful of people and assets - must conclude that the maladministration is worse than I had imagined.
A relevant article in the Times is here.
Sometimes it seems quite difficult to explain why the National Health Service fails to produce the quality service intended. There is a series of causes and effects. If you define just one cause and effect, you do not explain the whole thing. But here is just one part of the chain: the National Health Service wastes its own human and material resources on a vast scale.
This is a widely reported story in today's newspapers. This version is from BBC Online:
The Healthcare Commission found 45% of the theatre time in England allocated for day surgery was going to waste.
and further on,
The report, which examined 313 day surgery units in England, found one in 10 cancelled more than a third of the available operating theatre sessions and many patients had their operations cancelled at short notice.
In The Welfare State We're In, I looked at the story of how Capio, when it took over a hospital previously run by local government, significantly reduced the waste of time caused by cancelled operations.
Of course, government officials and those who still believe in state-run services will say, "OK, fine. I accept there is a waste problem here. We just need to focus on it and sort it out." Unfortunately this is a tempting and widespread self-deception. It takes us back to another part of the chain of cause and effect.
The waste arose in the first place - and has persisted for decades - precisely because the NHS is run by the state. The fact that hospitals are run by the state means that they do not have the right incentives to use their resources efficiently. A private hospital only makes money when the operation takes place. It has every reason to make sure everyone required for the operation is present. A state hospital can actually be better off when an operation does not take place.
"OK, fine. We will put in better incentives," say those who still want the state to run our public services. There is great reluctance on the part of many people to accept that the state is so bad and wasteful in its operations - and persistently, despite the best efforts of very clever and well-meaning people - that it is vain and silly to tell oneself and others that a solution has been found.
Those who believe the state is a good manager are like those who believe that Moggins the cat, can bark. First one of them goes to Moggins and say, "Bark for the public good". Moggins lies down and takes a nap. Then along comes a new minister and says, "No, no. I can make things much better. I can make Moggins bark. I have a new integrated barking programme driven by positive incentives." So the new minister says to Moggins, "I will give you half this meat now and the other half after you have barked". Moggins jumps up enthusiastically and eats the meat offered.
"OK, now bark and I will give you the rest!" Moggins looks longingly at the rest, circles a while, winds her tail around the minister, miaows in way that is as similar to a bark as she can manage. Then she becomes fed up, strolls off and turns her back.
And so and on it goes. We have had many successive health ministers, all clever people and all promising to make the NHS work well. And what have we got as a result of all their efforts? Operating theatres unused for 45 per cent of the time.
Isn't it about time we considered getting a dog?
The Healthcare Commmission press release is here.
Moeletsi Mbeki, brother of Thabo Mbeki and deputy chairman of the South African Institute of International Affairs, wrote an open letter to Bob Geldof in the Mail on Sunday. It was all the more devastating for being politely expressed by a man who lives in and really knows Africa:
I know that you and Tony Blair have been genuinely touched by the suffering of Africa.
But, ironically, the contribution you are making is exacerbating the problem.
The way things are at present, foreign aid, whether from individuals or government, promotes a lack of accountability in a country's rulers.
If a government has a budget of ,say, £100 million and has to raise it by taxing the people, the citizens will want to know how the money has been spent.
But if a donor says we will give you half of that £100 million in aid, the government's accountability is reduced by half.
And further on:
Your heart is in the right place, Sir Bob, but you do not appreciate the unintended consequences of what you are doing.
It [foreign aid] can lead to more starvation, not loess. If you keep dipping into the maize mountains of America and Europe to provide food to Africa, when are the Agrican people going to develop thier own technology to incease production to feed themselves?
He cites Ethiopa as an example of how this has worked in practice:
The reason it cannot feed its people is beause it lacks the storage systems - weevils get into the dry storage - and the threshing process is not carried out properly.
But there is little incentive to do anything about this. Stockpiles are not needed because every time there is a crisis the West is asked to give more food.
If you want to solve poverty in Africa, then help create an etrepreneurial system that will generate wealth for the people.
Given the hostility to George W Bush that was apparently shown by some people at the Live8 concert, it is interesting that he says, referring to 'plundering' by African leaders,
Few politicians in the West have ever questioned this systematic theft of a continent's wealth by its own rulers, fearing charges of racism and perpetuating colonialism.
Those who do, such as Goerge Bush, have been accused of being hard-hearted. But attaching reasonable strings to aid shows a clear head and not a hard heart.
It is a curious game that the national newspapers have played with Live8. Several of the sunday papers carried commemorative issues about the concert. Yet inside some, such as the Mail on Sunday, the Sunday Telegraph and the Sunday Times, carried articles that were distinctly critical about what the concert was trying to do. So Live8 was celebrated and criticised simultaneously.
This is Realnewspaperpolitik. Editors want to attract and keep young music fans and sympathisers with the politics of Live8 while at the same time expressing their actual opinions.
I know of one national newspaper which did not say anything bad about Sir Bob and Live8 on its main editorial page. But, it allowed its columnists to criticise Live8 elsewhere in the paper.
One can call it Realnewspaperpolitik but in truth but, more bluntly, it is hypocrisy. If these papers really believe that Live8 is wrongheaded, they should not report it, but not celebrate it.
I wish I could make a link to the Mbeki article but I cannot find the article on the Mail on Sunday website.
A friend took a child to St Thomas's with stomach pain earlier this week at about two o'clock in the morning. Although the girl was the only one in Accident and Emergency, it was two hours before she was told she had a bed in....Lewisham. She was then, in the early hours, transferred by ambulance to the Lewisham Hospital NHS Trust.
The ambulance man told the mother that the cost of the transfer was £600. There was also a cost, of course, in terms of the comfort and convenience of the ill child and the parents, who do not live near Lewisham. The ambulance man also told the mother that the hospital in Lewisham had stopped recruiting ambulance men and was seriously under-strength altogether. He actually said '50 per cent' under strength, which must surely be a wild exaggeration. However my friend did indeed get the impression that the NHS at Thomas's and at Lewisham was 'creaking at the seams'.
Although, in theory, her daughter had been admitted to Lewisham by St Thomas's, in fact she had to wait another two hours in Lewisham's Accident and Emergency department. Again, no other patient was there. Doubtless the waiting at the two hospitals will go down on the records as two waiting times of under four hours. A success. In fact, the poor girl had four hours waiting plus the time in the ambulance - an ordeal for someone in her condition, which by now was labelled 'suspected appendicitis'. The girl was at Lewisham Hospital for 48 hours, yet never saw the same doctor twice. Each doctor who saw her asked the same questions. There was no continuity of care. The mother does not think her daughter was at any point seen by a consultant. (Incidentally, the girl was not X-rayed or given any other kind of scan. I don't know whether, according to best international medical practice, she should have received some diagnostic work of that sort.)
The hospital in Lewisham was so short of nurses that they positively wanted the parents there to be present and - effectively - to do some of the nursing. One parent came in with a baby and then left. The baby screamed and screamed. There was no nurse available to comfort it, so the screaming just went on for a couple of hours.
We were told that all that was wrong with the NHS was that it was 'underfunded'. Now it is not underfunded yet it still provides service like this.
St Thomas's was founded at an unknown date, it appears, but certainly before 1212. It was named after Thomas Becket. A little more on its long history is here. And here is a lovely picture of the old operating theatre in 1930, before the hospital was expropriated by the state. It has been a great hospital. It is deeply sad that, under state ownership, it should have reached the stage that it keeps sick children waiting and then sends them away to somewhere else in the middle of the night, allegedly using up £600 in the process.
I would be interested to have any comments from others who may have experience of the situation in Thomas's, Lewisham or, indeed, elsewhere in the NHS.
Gordon Brown's poor record as chancellor is gradually becoming more obvious.
This week, more light fell on his bad policy of tax credits. But first a quick summary of the bad policies he has pursued:
1. He has raised tax heavily to pay for investment in a monopolistic healthcare system (adding to the problem by fighting any attempt to make it less monopolistic). The result: the country will be poorer than it would have been and people less well cared for when ill.
2. He took a pension system which was amongst the most successful and well provided for in Europe and has put it in crisis. Result: more people will be poor in old age.
3. He has increased the prevalence of means testing - with all its disadvantages (see The Welfare State We're In and previous postings. One of the results: reduced savings (which will, again, cause more people to be poor in old age).
4. He has dramatically increased red tape, waste and errors through complicated systems - such as tax credits - instead of using much simpler methods (such as higher thresholds for tax-free income). By wasting public money, he has made us poorer. Through red tape he has cost us money again and wasted our time.
Here is some of the coverage of the problems Mr Brown created through tax credits:
Hundreds of thousands of families have suffered because of flaws in Gordon Brown's £13 billion system of tax credits, a watchdog says today.
Ann Abraham, the Parliamentary and Health Service Ombudsman, says poor families are particularly vulnerable because of the way they have been forced to pay back money given to them in error.
In a hard-hitting report, she says that, without reforms to the system, "a sizeable group of families will continue to suffer not only considerable inconvenience, but also significant worry and distress".
She urges ministers to reconsider the way the Government pays tax credits, which are claimed by around six million families.
She also accuses the Treasury of misleading MPs about the extent of the problems and calls for claimants to be allowed to keep overpayments received as a result of error. The ombudsman's findings, which are echoed in a separate report today from the charity Citizens Advice, are an embarrassment to the Chancellor, who considers tax credits to be one of his major achievements.
The full article is in the Telegraph.
Polly Toynbee, in the Guardian, rode to the defence of tax credits although in the process she was good enough to lay bare more about how disastrous they have been:
If the sums involved are eye-wateringly huge - £2bn overpaid - that is because more families are getting these payments and the money they receive is far more generous than ever before. Even so, it takes the breath away to find that out of the 6 million families getting tax credits, almost 2 million have been overpaid by an average of £1,000 each.
For Ms Toynbee, it is a regrettable side issue that two million overpayments have been made. For her, the point is how generous Mr Brown has been and how clever he is politically to help the poor, despite the fact that - so she claims - the electorate does not like this.
She claims, incidentally, that there is no higher incidence of computer systems going wrong in the private sector than in the public sector. I wonder what evidence she has for that, assuming she has some? But in any case, should not prudent government policy allow for the fact that public sector computer systems, at least, tend to go wrong (and way over budget)? Would it not be sensible to make policies, where possible, that do not heavily depend on them?
But the major failing of her piece is the failure to consider much simpler (and thus less accident-prone) approaches such as introducing a high threshold for tax free income. Tax credits are generally repayments of tax paid. It is far simpler not to take the tax in the first place.
A second failing in her piece is to ignore the fact that many of the poorest and least able do not claim their tax credits. It is just too difficult. So they are not helped at all.
Today, Polly Toynbee has been reminded that her great admiration for tax credits is not shared by, er,
The Guardian was the first newspaper to reveal the tax credit system was in trouble and Jobs & Money has campaigned tirelessly for two years for the Inland Revenue officials to take a more lenient stance on repayments.
Last year, under the headline "Don't make it easy for the taxman" we told how Citizens Advice was advising claimants to check their records before agreeing to make overpayments. Given the official reports detailing how Inland Revenue systems make thousands of errors a month, it turned out be sound advice.
In the spring we offered further tips on how to appeal if the Revenue had begun to claw back overpayments ("Tax credit victims in fightback") and reported on calls by MPs for ministers to tackle the "tax credit shambles".
It would be a further two months before Dawn Primarolo, the minister in charge would concede to conducting a limited review. Calls for her resignation this week were rebuffed by the government.
The government has resisted calls for an overhaul of the tax credits system ever since it was launched in 2003 amid chaos and confusion.
Ms Primarolo ordered a limited review last month, but this week's critical reports have failed to persuade her the system is flawed.
She has also ignored calls by charities representing low income families, MPs and civil service unions, which have campaigned for a moratorium on demands for tax credits to be repaid until basic defects in the system are investigated.
"Chaos", "confusion", "shambles"? Not a problem for Polly.
Rather strangely, neither the Telegraph nor the Guardian appear to have covered a story made a big impact in both the Mail and the Express this week. It is not a trivial, celebrity story but one that goes to the heart of one of the big issues of the time: whether the NHS model of healthcare can ever deliver a first class service.
A consultant surgeon, Mike Lavelle, has resigned from the NHS and leaked a letter in which he made a powerful attack on the way the NHS works.
"The delays in operating theatres are quite frankly scandalous" he says.
"I have no doubt that the service is grossly overmanaged now.. there has been an almost unbelievable increase in NHS employees who contribute nothing to the treatment of patients. But if you go onto my ward the nurses are struggling to look after the patients..."
"For years now, I have been stopped from doing my job in the NHS by the lack of facilities, but in public, the politicians (in particular Alan Milburn and John Reid) have blamed the consultants for the waiting lists. This is extremely demotivating and demoralising", Mr Lavelle wrote.
"It seems the Government thinks that if only they could get the consultants in the NHS to work harder, then waiting lists would be a thing of the past.
"You may not believe this but I have found in the past 10 years or so that the harder I work in the NHS the gloomier managers get because I am spending the limited resources. The delays in operating theatres are quite frankly scandalous. I have complained about this for years, yet nothing has been done.
"In the end, the taxpayer is paying twice for the operation; once when I am sitting around doing nothing, either because of delays in getting patients to theatres or because of lack of beds, and then again when the operation is farmed out to the private sector."
The above quotes are taken from the limited version of the story on the Daily Mail website.
From the printed version, I would add that Mr Lavelle also criticised the employment of a 'Service Improvement Facilitator' who visited the the endoscopy unit to inquire about the number of endoscopes (in instrument for internal examinations).
"Everybody knows that to improve the service we need a second room up and running and some new endoscopes, but instead of that we employ these people to go around interfering and collecting inaccurate data."
"A year's salary for this person would probably but a new colonoscope and we could have a new scope every year for the next five years!"
"It is my impression at the moment that there always seems to be money available to appoint new managers, but if you go on to my ward the nurses are struggling to look after patients because the establishment is inadequate."
The criticisms of Mr Lavelle indicate some of the answers to the question which we can expect people to be asking more and more in the next few years: 'why has the NHS improved so little when so much has been spent?'
1. Waste of money when operating theatres are not used and highly qualified staff (not to mention the patient) are left hanging around
2. Waste of money on administrative staff which could be better spent on frontline staff.
Some politicians might respond, "Right-o, we will demand that operating theatres are used more efficiently and we will cut back on admin staff". They will imagine that yet another diktat from the centre will solve everything. How many times has this naive idea got to be tried out before it is understood that it will not work?
The problems identified result from a systemic problem. State monopolies tend to be extremely wasteful. They do not have the same incentives simultaneously to save money and serve the customer very well. Their 'customer' is the central government. Their employees' jobs depend on doing what central government demands. So they do what central governments demand. They fill in forms. They report back on how they have carried out instructions. They need more staff to do this. This is the priority and never mind the patients, the waste or all common sense. The NHS is an inherently bad system because it is a government monopoly. Only when the NHS is reformed in a way that it ceases to be a government monopoly - in other words completely breaks with the Bevan model - will it have the remotest chance of being good.
Incidentally, I would be interested to know what Mr Lavelle is going to do next. Neither the Express nor the Mail reveals that. Will he work in private practice, retire or work abroad?
Five million out of 5.7 million public sector employees (88 per cent) have final salary pensions. Meanwhile only 3.6 million out of 22.5 million private sector employees (about 16 per cent) have final salary pensions.
These figures, accourding to the Sunday Telegraph, will be published by the Government Actuary's Department on Thursday. There have been a fall of one million in those in the private sector who are on final salary schemes over the past five years. That is largely the effect of Gordon Brown's tax on dividends received by pension funds which has helped make final salary pension schemes just too expensive for private companies. But what is too expensive for private companies, is not too expensive for taxpayers to pay for.
The civil servant, the teacher and the hospital manager all get relatively luxurious, final salary pensions, courtesy of taxpayers. The MPs and the prime minister get the most luxurious pensions of all.
This is the 'producer interest' at work. Politicians and civil servants create the rules which favour themselves, rather than those they are supposed to be serving. It is easer for public servants to pursue their 'producer interest' than for those who are in private companies. That is a fundamental reason why governments are less efficient in all their activities. They waste money. In this case the waste arises becaue it would be perfectly possible to hire the same public servants at the same wages - or only fractionally higher - without their relatively luxurious pension schemes. Public money is spent which could have been saved.
The taxpayers pay for this waste and these taxpayers include those paying income tax on incomes of a mere £5,000. In other words, people who are very poor pay tax to finance the unnecessarily high pensions of public servants. It is, of course, a scandal. But don't expect the BBC to be outraged. They are public servants. And don't expect politicians to say anything. They are a) public servants and b) don't want to offend the other 5.7 million public servants who are also voters.
All this is without going into another scandal in public servant pensions: the all-too-easy and frequent early retirements in the fire service and several other public services.
Baroness Warnock wrote a report over 25 years ago in which she called for children with 'special needs' to be included in mainstream schools. The 1981 Education Act incorporated her recommendations. Now she is apparently going to re-cant and say that the pressure to include pupils with special needs in mainstream schools causes "confusion of which children are the casualties". The following article appears in the Daily Express today alongside an article by Bob Black, saying he is pleased that his 17-year-old daughter Morwenna, who has Down's Syndrome, has been to a mainstream school:
Baroness Warnock's report started a movement which has led to some education authorities positively insisting that disabled children should go to mainstream schools. A policy started with the friendly, 'inclusive' ideas of the 1970s has gone badly wrong.
Children with learning difficulties are not all the same. There is a big difference between a child who is a bit slow and a severely retarded paraplegic. There is a need for flexible thinking. It is marvellous that Bob Black's child, Morwenna, has done well in mainstream schools. But there are some inner city comprehensive schools where even ordinary children are bullied. It would be taking a terrible risk to send a Down's Syndrome child to such a place. Morwenna may not have been bullied but that does not mean that many other disabled children have not been, and badly.
It is true that a child with problems can sometimes benefit from the example of more able children in a mainstream school. The presence of such a child might also improve the attitude of other children, making them more accepting of disabled people. But let us remember hard fact number two: mainstream schools do not have special training in all the different disabilities. I am a governor of a state primary school which has six children with 'statements' of 'special educational needs'. Each one is different. The staff cannot possibly be well versed in them all.
Then there is the grotesque 'special needs' bandwagon that has built up. The proportion of children with the worst problems who have 'statements of need' has tripled since 1991. This is a farce and a scandal, as Baroness Warnock now admits. It probably has a lot to do with the fact that schools get more cash when a child is 'statemented'.
The proportion of children with less acute problems has also jumped - at least by a third and probably far more. Astonishingly a fifth of children in school years three to seven are now supposed to have 'special educational needs'. This is simply beyond belief. There has not really been a mass outbreak of childhood learning difficulties. In many cases, the problem is not the children but the teaching. Schools for the last two decades have been infected by poor methods of teaching children to read and write.
There is terrible waste in a new 'special needs' industry. Vast amounts of expert time and paperwork goes into drawing up the 'statements' of need. Far less is spent actually giving children useful things such as speech therapy. A vast army of support assistants sits next to 'statemented' children. It is far from clear that all the children who are given this expensive attention truly benefit.
In Florida, parents of disabled children can get vouchers which enable them to get their children out of their state schools and into different state schools or private schools instead. Fifteen thousand children have taken advantage of the programme. Surveys have revealed that the children have become significantly safer from bullying, happier and have done better academically. If we really want to look after children who have difficulties, we should give parents here the same choice.
(A useful source on the subject is the essay What are special educational needs? by Dr John Marks which was published by the Centre for Policy Studies in 1999. The government's latest figures for children defined as having special needs are here. The fall in the figures in recent years looks rather strange and there is some hint in the notes that this might be due to different methods of collecting the figures. If anyone has further information on why the official figures have fallen, I would be glad to hear of it.)
Earlier this week, the Conservative Party collected together some data about how the awesome way government has wasted money on computer projects:
...a new courts computer with an original budget of £146 million, rocketed to almost £400 million; a move of the GCHQ spy centre computers to a new building cost a staggering £450 million, instead of the projected £20 million; and a new national insurance payments system turned out at £90 millions over budget, after mistakes and problems had to be corrected.
When someone suggests that more money should be given to governments of third world countries to help them 'make poverty history' remember this article in Saturday's Daily Telegraph:
Five months after the tsunami struck, killing 40,000 and leaving 500,000 homeless in Sri Lanka, more than 100,000 of the poorest victims are still living in tents or crude temporary shelters.
Despite almost unlimited resources - the relief fund stands at more than £1.75 billion for Sri Lanka alone - victims are cooped up in camps waiting for news of progress that never seems to come.
Aid agencies keen to press on with rebuilding are being frustrated at every turn by the tangled and all-embracing bureaucracy of the central government. Shipping containers remain stuck at ports, vital building plans await approval and incompetent officials ignore the advice of specialists.
This week, as the first monsoon rains arrived, agencies were striving to move thousands of people out of their tents and into solid shelters before camp sites turned into quagmires.
After months during which the situation has deteriorated and no one has spoken out for fear of upsetting the highly sensitive government, the World Bank finally broke cover this week.
Gordon Brown and others appear to think that government to government aid is the answer. In fact, as this story illustrates, governments in most impoverished countries are the problem, not the solution.
Full article here.
The following comment on the government inspection of care homes seems worth putting up as a posting, too. I asked the author for a glossary of terms for those who are not familiar with all the organisations he refers to. They are at the end.
The government regulations are amazingly bad, cost a fortune to both care home owners and the public sector, and achieve nothing.
There are several problems.
(1) They are applied quite staggeringly inconsistently. Some hammer people for minor or invented infractions, some just ignore them. This tends to (IME) bias towards those run by the Public Sector. largely because the inspections are done by the former colleagues of the people in the public sector ; back scratching stuff.
It's a bit like Fire Regulations. With LEA schools the line has always been basically getting them up to scratch would cost an absolute fortune, so they are effectively exempted. Private Schools do not have this luxury. This seems to apply in NCSC/CSCI/CHAI as well.
(2) The Inspectors are laughably ignorant about the actual work, literally, I once had to leave the room because I had a fit of the giggles. It is tickbox mentality run riot. Because they have no clue, they focus on minutiae like how big the windows are, because they have no qualifications or experience to evaluate what is actually happening.
The comments in (1) still apply ; the application of tickboxes is variable to say the least. They write what they want.
(3) The standards have to be measured. This forces towards things which are quantifiable. Quality of Care, Happiness of Patients etc is not quantifiable. Forms and Records are. So they require more and more forms and records, which makes less time available for the job of actually caring. Inspection is usually about 70-80% looking at records and forms, and has been done without viewing any practice at all. This is like OFSTED inspecting a school without ever seeing a classroom or child.
(4) They can say and do what they like. The complaints route is all to them and their above levels, and they will ignore the ombudsman, basically. There is a tribunal, but the burden of proof is on the complainant, not on CSCI. A variation on OFSTED is you always get the same inspector, so if you make a complaint the same person will come back effectively wanting revenge. So no-one complains, though I know no-one who thinks any of them are competent.
(5) Like any quango, the main aim is to increase its reach, budget, areas of control. Much effort goes into this. There is a laughable punch up going on where I live between SSD & CSCI, which involves them refusing to invite each other to meetings etc. (for the benefit of the children, doubtless). This is because both want the power and money that comes with "child protection"
(6) Because they don't have to pay for anything, the requirements extend endlessly as a back covering exercise. It is always in their interest to demand more staff, more targets, more forms, more systems. This increases costs, which most users cannot afford and SSDs will not pay. So care home owners sell up and quit, or they focus purely on meeting the targets. You get the impression that as long as the forms are okay they don't care about what is actually happening.
The worst cost increase is staffing. They are demanding minimum levels of staff training, which is fine, except someone has to pay for it at some time. Care Homes are run to some extent on cheap employees to do mundane jobs. Having everyone at NVQ3 (another rule ignored for public care homes and schools) racks up employment costs spectacularly, let alone training costs. At the same time, they want more staff (except for Local Authority provision).
(7) As a carry-on from (1), LAs are dodging the targets by redefining care homes as "rented accommodation with 24-hour support". This way most of the regulations don't apply. So they dodge them (something Private orgs aren't allowed to do), even though the practice is identical. To be fair, there's nothing actually wrong with the homes, they just don't tick the boxes.
(8) It repeatedly reorganises at great expense. Originally it was done by SSD. Then they all went to work for NCSC (late 2002). Two weeks after NCSC started, they were told they would be converted to CSCI and CHAI (early 2004). Now they are going to be OFSTED and CHAI. Imagine the money wasted !
IME : In my experience
LEA : Local Education Authority ; run public sector schools, pretty
badly. It's worse than you can possibly imagine.
SSD : Local Authority Social Services Departments ; roughly
divided into "Children & Families" and "Adult" divisions, though they
are trying to combine this back and add control over education. Yet
another bureaucratic turf war. Also responsible for Child Protection,
but are squabbling with CSCI over this at the moment. Both sides want
DfES : Department for Education and Science. *Also* squabbling for power with NCSC/CSCI/CHAI, over who has control of Residential Mainstream and Special Schooling.
NCSC : National Care Standards Commission, monitoring Residential
Accommodation, Hospitals, Fostering, OAP Care, Residential Schools,
Sheltered Housing and all sorts of other similar stuff. Typical Blairism Monitoring and Targets organisation. Basically a "OFSTED for Care Provision".
Later (announced 2 weeks after opening !) split into :-
CHAI : Commission for Healthcare Improvement
CSCI : Commission for Social Care Improvement
Which does the same thing. Not quite sure where the split is. I think
CHAI does Hospitals, CSCI does the rest but wouldn't swear to it. I
*think* that CSCI are going to be subsumed into OFSTED, this is one of
Gordo's red tape reductions. I'd bet my life savings the same people
will be doing the same jobs .... it's a joke.
Incidentally, as far as I can tell despite all these switches the same
people (literally) do the same jobs in the same way, they just change
the name and bring out masses of new initiatives and reprint all the
OFSTED : Office for Standards in Education. Quango for schools
NVQ : National Vocational Qualification.
The husband of a trainee nurse emailed me and mentioned that a third of the trainees drop out after only eight months. I asked why. This is his reply, which makes it appear that the training of nurses has gone beyond absurdity into a scandalous misdirected use of taxpayers' money:
They just appear to get fed up and wander off! There doesn't seem to be a "reason". The practice part of the job was hard work, but they were dropping well before that. One left four days after the start of the course.
To be honest, it's a complete skive as far as I can see. On Monday, she does about 90 minutes. Tuesday is a full day, Wednesday about half a day, Thursday is a "study day" e.g usually nothing, and Friday is a full day.
I reckon it is about 40% of "full time" study, most of which is lectures. A "full day" is more like 10:00 to 3:00 not what you are I would consider a full day. If they got on with it, they could probably do it in 2 years of full time courses.
The essays are short and easy (2 x 3000 word essays per year) and you get 6 weeks to do them in (and more time off to do them in). It's not particularly high level stuff at all; you can't write anything in depth in 3000 words really, and the essays are multiple-topic, so you are really only writing a few hundred words on each part. The hard part is fitting it into 3300 words (you can go 10% either way). I spent an hour pruning her first essay just to get it down to size.
I *think* they are used to having things on a plate and can't cope with being expected to work for it, be marked on their essays and so on, general lack of gumption, and I suspect they think it's going to be like "Casualty".
Like any other caring job, there's a fair amount of messy stuff and that puts people off.
And I suspect it's the old "instant gratification" requirement. I
suspect you've read "All Must Have Prizes", it's like that but worse. It's also the move towards degrees in Nursing, i.e. an academic qualification. Nursing is not an academic skill really IMO.
The work appear to bear little resemblance to actual "nursing" ; it is all the codswallop about "facilitation" groups, they have discussions and presentations a lot of the time, there are reams of documentation which seem to be box ticking jobbies of the type that the DfES produces daily, producing evidence that course targets are met presumably to be fed back purely to tick more boxes. A background in teaching was handy for me to translate this into coherent English ;-) [smile] I think the end of year "exam" is a
short multiple choice test.
There was no training (literally) in actual useful skills - taking
pulses and so on - until the week before the first placement, when they had a few days of crash training. Not a good way to learn a skill really.
The bit that is hard is the practice ; this has involved 8 or 9 consecutive 10 hour days with awkward shift patterns apparently constructed at random - and lots of weekends ; my wife has said that there seems to be more students about at weekends, and certainly she's worked for more Saturdays and Sundays than anything else -
but she can't really complain. Certainly her shift pattern would be
unworkable over a long period ; you would just simply collapse. She says friends of hers have done 7 days in a row 12 hour shifts. But I don't think this has made a massive difference, people were dropping out on the above timetable.
I don't think it is at all unusual. A friend of ours is in the last year of a Mental Health Nursing course at the same hospital reckons about a third of the students are left from the start 2 1/2 years ago.
No-one appears bothered about the dropout rate. It appears to be
accepted as the norm.
An email received today:
I've recently read your book and you raise a lot of good points. I teach in a college that retrains unemployed disabled adults and it is only too apparent that the welfare system has hindered as well as helped a large number of our students in the ways in which you describe. For many the financial incentive to work just isn't there, especially those with families, although often we are sucessful in changing peoples outlook and raising their aspirations.
In a lot of cases the disability, physical or mental, is secondary to the problem of a poor basic education in the first place. Without basic literacy, numeracy and organisational/reliability employment prospects are massively limited. We are certainly seeing a large proportion of youngsters for whom you wonder what they actually did at school.
It's pretty clear that for a long time gov't thinking was on inclusion in mainstream education and organisations, charity based and specialised like ourselves, were not flavour of month. There is now a realisation that this approach does not work for everyone and has left many people marginalised as mainstream providers have not got the resources or skills to give the level of support necessary. This seems to be changing but the problem that a lot of charitable organisations have when applying for funding is the enourmous levels of beaucacy that accompanies any application e.g. setting targets,
review procedures, equal opps, inspection and auditing etc. In other words, introducing the same levels of inefficieny and inflexibility that the state insists on for itself!
More and more state spending is going towards paying the pensions of public sector workers.
'In Greater Manchester, total pension payments for fire-fighters are put at £30.4 million in 2005-06, compared with salary costs of £74.9 million. This amounts to a doubling of pension payments in the past eight years... Council tax payers in the area have seen the amount that they pay for fire services rise by 68% over those eight years… [But] net of inflation and pensions, the Fire Authority’s budget has actually reduced by 7% over the period.’
There is nothing wrong, in principle, with money being spent on the pensions of public sector workers. The problem is with the practice. From the taxpayers' point of view, these pensions are unnecessarily and wastefully big, for two reasons:
First, they are unnecessarily generous to attract people to work in the public sector. Most people when they start on a career in their 20s, have little or no concept that public sector pensions are vastly higher - in relation to the salaries - than those provided by the private sector. So the employees could be hired to serve us at lower cost.
Second, these luxury pensions are then abused and effectively inflated still further. Police and firemen and other public servants take early retirement on excellent terms far more frequently than people in the private sector.
Why does this happen? It is a simple case of the 'producer interest' at work. Those who are in charge of such things are, at the same time, part of the workforce that benefits from 'generosity' (as some may call it) or 'selfish waste of taxpayers' money' (as it should more rigorously be viewed).
The NHS is the world's third-largest employer with a million people on its books, second only to the Chinese Army and Indian railways. We spend some £80 billion a year on the NHS, equating to £1,400 annually for every man, woman and child. Despite this the number of NHS beds in England has halved in the past 25 years.
The average British woman will have 2.2 healthy pregnancies in her lifetime - almost enough to keep the UK population stable - but will give birth to only 1.7 children. The difference is accounted for by the number of abortions.
The number of people working in the public sector has increased by 10 per cent since 1998, accounting for some half a million of the new jobs created since Labour came to power.
Total public sector employment in 5.29 million, up from 4.71 million in 1997.
In 1981, 600,000 people claimed incapacity benefit. Now it is 2.2 million.
The greatest increases in recorded crime since 1997 have been in drug offences (509 per cent) and violence against the person (281 per cent) and there has been a drop in burglaries by nearly a fifth.
More than half the households in Britain have less than £1,500 in savings, and a quarter have no savings at all.
Teenage birth rates in Britain are twice as high as in Germany, and five times as high as in Holland.
150,000 children are educated at home, and the figure is rising. Bullying, harrassment and religion are the reasons most cited by parents for taking their children out of school.
From Britain in Numbers published by Politico's and serialised in today's Daily Mail.
The star rating system for hospitals is being phased out. It has been a flop but that does not mean that money has stopped being spent on it. It also does not mean that money will cease to be wasted (often actually doing harm, in addition to the waste of money).
This from BBC Online:
"Star-ratings have had their day," said Michael Dixon, of NHS Alliance. "This year we will have star ratings without them being taking too seriously."
However the Healthcare Commission said the ratings were still relevant.
The last star-ratings will be published during the summer, but experts have said they will not be taken seriously because of the changes.
Star ratings, only introduced in 2001, have been overhauled after complaints they were too onerous and target-driven.
All 572 trusts faced three-yearly inspections, costing £150,000 a go.
From the latest Adam Smith Institute email newsletter:
My friend John Hughes, CE of Cygnet Health Care, has sent me a neat little squib mocking the tide of jargon in so many government services. It's basically just three columns, and you pick one word from each and string them together. He calculates it can generate up to 91,125 authoritative buzz phrases. Saves so much time writing reports to ministries. Here's a sample:
Proactive Performance Strategies
Collaborative Partnership Process
Developmental Community Potential
Resource-rich Governance Approaches
Interactive Organizational Pathways
Intensive Consumer-led Modifiers
So from that you can generate "proactive consumer-led approaches" or
"developmental community strategies" or pretty much anything you like. If only some of it actually delivered any service to the public!