Wednesday, July 02, 2008

NHS bosses still dreaming

After 60 years, the NHS has signalled the end of cheap-and-cheerful, any-colour-so-long-as-it's-black healthcare. That's about 30 years after manufacturing, retailing, telecommunications and the rest of the service sector embraced the idea that the customer is king, and what he (or she) wants is quality service. But let's not quibble. Lord Darzi's review sets quality of care first, and everything else a distant second. Almost all the detailed changes he proposes are designed to raise standards. Doctors and hospitals will be measured by the quality of care they deliver, and rewarded accordingly. Patients will be asked their opinion, and other more specific outcome measures - such as how many patients die - will be used to determine just how good their care has really been.

In general practice, the Minimum Practice Income Guarantee (MPIG) will go. Income will instead depend more on the Quality and Outcomes Framework, which measures what GPs do, rather than what their historic income has been.

Hospitals that deliver a classy service will be paid more than the rest, under the tariff that determines the cost of every procedure. Everybody will publish annual Quality Accounts, equivalent to their yearly financial accounts.

Primary Care Trusts will be forced to pay for treatments passed cost-effective by the National Institute for health and Clinical Excellence, and Strategic Health Authorities given a legal duty to encourage innovation. Patients will get enhanced rights of choice over where they are treated, harnessing market power to raise standards. The theme is clear. "This whole report is about quality," Lord Darzi said. David Nicholson, chief executive of the NHS, said: "Quality is to become the organising principle of the NHS".

But can the service deliver? Historically, it has always valued shifting large numbers of patients through their episodes of care as a greater good than ensuring they were as well-treated as medical knowledge makes possible. Central targets enshrined this principle, to the fury of clinicians.

Lord Darzi now claims to have listened to the clinicians, and shaped his report from what he heard. "This is not a document pulled together by a small group of people in the Department of Health" insisted Mr Nicholson, as if we might possibly have suspected it.

At issue is whether the levers are strong enough to bring about change. The document assumes that quality improvement will have no victims. But better quality can only come about by chasing out bad: that means eliminating poor GPs, closing failing hospital services, or even entire hospitals. Otherwise there won't be the money to reward the good. These changes are painful. Lord Darzi envisages them being driven locally, but his chosen instrument, the primary care trusts, are weak reeds. Hitherto most of them have been easily managed by ingenious GPs and popular local hospitals. Most patients don't even know what PCTs are: and if PCTs try to do anything tough, they are easily characterised as "NHS bosses" cutting services.

There are also some spectacular gaps in the promises the documents make. The NHS Constitution - a "declaratory document" said Lord Darzi, for which read the usual well-meant pieties - makes only one new promise, that of universal patient choice. But when pressed, the Health Secretary, Alan Johnson, seemed unsure how that would apply to popular GPs whose lists are full, and Lord Darzi disabused anybody of the idea that it means you could choose a particular surgeon - for instance, him.

In his team of colorectal surgeons at St Mary's Paddington, all were equally good, he insisted. But if choice doesn't mean the right to choose a particular GP or a particular consultant, what does it mean? And if you can't really choose, how can bad practitioners be driven out to make way for better ones? Competition is a bloody business, as a million corner-shops run out of business by the supermarkets can attest.

Lord Darzi's report lacks any acknowledgement of this. It simply envisages an NHS aspiring ever upwards to unimagined levels of quality and care, leaving nobody behind: no victims, no bankruptcies, no tears. Life isn't like that.


British school segregation increases over ten years

Schools are now more segregated by poverty than 10 years ago when Labour had just come to power, Government figures indicate. Most areas saw an increase in the division of pupils, by school, depending on whether on not they took free school meals. The data also shows that, by race, Pakistani and Bangladeshi pupils are the most segregated between schools.

A report released by the Department for Children, Schools and Families, analysed statistics on school composition. It found: "Grammar schools have a lower than average incidence of pupils eligible for free school meals and pupils classified as special educational needs. "But they have a higher than average incidence of ethnic minority pupils, largely due to higher than average number of Indian pupils."

Some local authorities which had grammar schools saw a huge influx of secondary school pupils from neighbouring areas, the report said. In four council areas which had selective schools, more than 60 per cent of the secondary school intake came from other authorities. The report added: "On average, selective local authorities gained above-average attaining pupils in Year 7 and lost low-attaining pupils."

The research considered the extent to which children from deprived backgrounds were concentrated in particular schools. It found: "The level of segregation by free school meal, in primary and secondary schools, increased for most local authorities between 1999 and 2007. "Nationally, Pakistani and Bangladeshi pupils were the most segregated between schools. However black African and black Caribbean pupils were more segregated between local authorities."


Britain: Leftist elitists boil with hate for their Conservative mayor

I was leaning on the wall in a Soho cellar last week, idly scanning acts at the weekly Comedy Camp, when an un-comic train of thought began. The host, Simon Happily, launched into an untypical rant about his intention to boycott the "Pride" march on Saturday. As every Archers listener knows, this is one of the PC pinnacles of the year, when gay pride storms across the capital with rainbow flags, arresting outfits and flamboyant humour.

It should be a matter of quiet satisfaction that London is one of the world's safest places to hold such an event. In cities from Moscow to Jerusalem these marches have been banned or met violence. London is also distinguished by having a community ironic enough to host the Duckie collective's mocking echo entitled Gay Shame. They plan to "celebrate" rival concepts of masculinity with "the aesthetic of a giant minicab office - sticky, brown, stained, a bit pongy... no pink, no heels, no make-up, no floral patterns, no humanity". Oh, come on - what's not to like?

But Mr Happily's rage against the main Pride march was because on the lead float will be the Mayor, Boris Johnson. Who once, musing on civil partnerships, wrote that: "If gay marriage was OK - and I was uncertain on the issue - then I saw no reason in principle why a union should not be consecrated between three men, as well as two men, or indeed three men and a dog." Mr Happily quotes this as proving that Boris's presence makes Saturday's whole march "a travesty".

So I started to study the relationship between Boris Johnson and this particular interest group - not because of gay issues, but because it resonates with so much else about the hysterical way we argue in this political age.

The demonisation of clever, wayward Boris throws light on our worst sickness: the politics of enmity. The bald fact is that while the jury is still out on his actual effectiveness, Boris Johnson is an intelligent libertarian with a real desire to do something practical instead of just catcalling from the sidelines. I admired him when he first stood for Parliament - less lucrative than journalism at his starry level - because with unusual shamefacedness he muttered to an interviewer that he wanted to "do his bit". I tended to believe him. Those who write from inside glass houses, never risking electoral humiliation or boring committee-work themselves, should be careful how they throw stones.

But the new London mayor has demonstrated the perils of travelling from the commentariat to public office in a vindictive political culture. To succeed in modern politics you should take care to be a bland, self-preserving, sober, drugless, funless, dull-witted bore for years beforehand. Boris Johnson hobbled himself by being human, erratic and witty. His back catalogue of writings will follow him whatever good he does in real life: the politics of enmity decree it. In the mayoral campaign he was branded a racist merely because of two flippant expressions he once used. They occurred in pieces which, if read in full, were guying the patronising (slightly racist, indeed) way that British leaders love to escape unpopularity at home and be greeted by smiling Commonwealth ceremonial.

He was branded homophobic (though he finally voted against his party line over Section 28) because of the "three men and a dog" and a couple of equally flippant remarks. But read it with any care and you see that he was playing with the idea of mutable social values. It was clumsy - I doubt he had grasped the real argument for civil partnerships, which is social, financial and legal justice - but it was not hostile. Moreover, he has got the point since, and voted in Parliament for the new law. Boris Johnson is not a homophobe. Hedonists rarely are.

Yet during the election campaign lies were spread that he would abolish funding for the Pride march; on race and class too he was hammered without regard to truth.

A disgusting attack in The Guardian called him "this bigoted, lying, Old Etonian buffoon... moneyed creep... he has lied flagrantly, flamboyantly to save his marriage... despises people who are not of his class, which means all of us... a snob's London is a Monday-to-Thursday kind of affair behind fusty doors, in clubs that only just let women in, let alone plebs, in restaurants that don't have prices on the menus, in the Regency offices of magazines whose only distinction is that all the staff are shagging each other".

That reads just as nastily as any right-winger's jeer at sandalled lefties or BNP rant about immigrants. Another writer used the hilariously golf-clubbish expression "he is not one of us" and a pother of petulant glitterati were wheeled out to condemn him - Alan Rickman, Vivienne Westwood, Will Self, Ben Okri, half of Mitchell and Webb, Arabella Weir - that woman who wrote "Does my bum look big in this?" - the usual bien-pensant suspects.

Feeling safe from any charge of hate-crime themselves, they called Johnson everything from racist to mad (not to mention Etonian). Arabella Weir promised that if he won she would throw herself in front of a horse, go on hunger strike and chain herself to railings. I see no reports of her having done so.

It is hate that fuels such attacks, not love of your fellow man. This Saturday those not afflicted with hate-addiction should find it enough that he now backs civil partnerships, regrets the offence and "believes in loving relationships between all sorts of people". He will spend Saturday on a float to prove it, braving whatever they throw at him.

And some will. Once a cardboard demon is created, whether asylum-seeker or Etonian, it is not enough to attack him for what he actually does. Rage is provoked entirely by the need to be enraged. Borisophobes feed their addiction by jeering at his perceived (and entirely earned) wealth, at his accent, his education, his imaginary toff lifestyle. They are no better than any other hate-junkies: racists, bigots, Islamists and Islamophobes, gay-bashers, or the 1950s snobs who used to claim that council tenants kept coal in the bath. Putrid loathing spurts in all directions, fed by the media and opportunist politicians, and sometimes, alas, by clerics. It is all despicable.

To quote Mayor Johnson himself in an interview with the Pink Paper: "All irrational human hatreds are always really about your own feelings about yourself in some way. Anyway, I think it's all bollocks and the sooner we get over it the better." Quite.


Can science save us from superbugs?

New antibiotics might help to fight hospital infections but socialized medicine systems might still not use them on cost grounds. Comment from Britain:

Last Thursday the Office for National Statistics confirmed that more than 20 patients a day now die from the superbug infections, MRSA and C difficile. NHS practice has been poor. MRSA (methicillin-resistant staphylococcal aureus) is a bacterium that many people carry, safely, in their noses. Yet when people are weakened by sickness, MRSA can invade the bloodstream and kill. In Scandinavia, Holland and Harley Street (three places where MRSA is rare) carriers are screened and treated before being admitted to the wards, but the NHS has been slow in following suit.

Clostridium difficile is another bacterium that many people carry safely (in their intestines), but when hospital toilets are poorly cleaned, when wards are overcrowded, or when people fail to wash their hands, patients will acquire C difficile from each other and, in their weakened state, die of diarrhoea. Can science offer a technological solution to the NHS's failings? Can we invent new antibiotics? Two papers offer hope.

Our bodies make their own natural antibiotics, of which nitric oxide is one. In a recent paper in Science, Dr Fang of the University of Washington, Seattle, showed that MRSA produces a special enzyme that detoxifies nitric oxide. That is why MRSA can kill us.

Meanwhile Dr Pierik of Philipps University, Marburg, has shown that C difficile's enzymes are equally special. They are ancient. There is no oxygen within our guts because the bloodstream does not extend into them. But billions of years ago - before green plants evolved - there was no oxygen in the Earth's atmosphere either. Yet bacteria were already established, and C difficile still uses the enzymes of its primordial ancestors to flourish without oxygen.

Antibiotics work as "magic bullets". It was Paul Ehrlich, the German microbiologist, who in 1909 invented antibiotics by identifying chemicals that, magically, disabled bacterial but not human enzymes. But to find his bullets, Ehrlich had to search randomly. He infected rabbits with syphilis and he dosed them with random chemicals. He named his first drug Salvarsan 606 because it was the 606th chemical he tested that finally cured the rabbits.

Drs Fang and Pierik now proffer the hope of a focused future. Now that we can characterise the key enzymes of MRSA and C difficile, we might design new antibiotics systematically, not randomly. Science may indeed rescue us from the NHS's failings.

Yet the NHS, as a state monopoly, will find new ways to fail. And we will have ourselves to blame. The insurance-based systems of continental Europe - whose hospitals have bed occupancy rates of only 75 per cent and whose hospitals, being separately owned, compete for patients - are better than our own. But the British resist reforms that cost them money.



Since Gordon Brown on Thursday launched what he called "the greatest revolution in our energy policy since the advent of nuclear power", centred on building thousands of new wind turbines, let us start with a simple fact. Nothing conveys the futility of wind power more vividly than this: that all the electricity generated by the 2,000 wind turbines already built in Britain is still less than that produced by a single medium-sized conventional power station. There are nearly 50 nuclear, gas or coal-fired power plants in Britain today each of which produces more electricity in a year than all those 2,000 turbines put together.

I make no apology for returning to this subject because the "100 billion pound green energy strategy" published last week, by what is now laughably known as the Department for Business, Enterprise and Regulatory Reform (BERR), contains not only many smaller deceptions and self-deceptions but one so great that almost everyone has fallen for it. The starting point is the EU's requirement that, to combat the "threat of climate change", we must drastically reduce our CO2 emissions, chiefly by building thousands more wind turbines.

It is quite clear from the paper that BERR's officials know we haven't the faintest hope of meeting our EU target in this way. So its number-crunchers have been working overtime to squeeze down the amount of energy we source from wind to the lowest figure it thinks can be made to sound plausible. Until last week BERR had been claiming that our EU requirement meant that we must generate 38 per cent of our electricity from renewables, the largest contribution coming from 11,000 offshore turbines, representing 33 gigawatts (GW) of capacity. But all this has changed dramatically. They now talk only about the need to meet 32 per cent of our total EU renewables target through our methods of electricity generation, with only 32 per cent of that needing to come from wind - and that, they say, can be done with a mere 7,000 new offshore and onshore turbines.

However, our present generating capacity is 76GW. By 2020, on projected demand, to replace one third of one third of our capacity with wind power would mean generating an average of 10GW. And herein lies the central misconception which bedevils the entire debate. Because of the wind's intermittency, turbines generate on average at less than a third of their capacity. Thus to contribute 10GW would need 30GW of capacity, which would require up to twice as many turbines as ministers are talking about - needing to be erected at a rate of more than four every working day between now and 2020.

In practical terms, even if they grossly bend the planning rules (as MPs voted for last week), there isn't the remotest chance that anything like this number of turbines could be built in time to meet their target. For instance, the world only has five of the giant barges that can install monster turbines offshore - and for more than half the year our weather conditions make installation impossible anyway.

But in addition we should also need to build at least 20 new conventional power stations simply to provide back-up for all the times when the wind is not blowing - at a time when, within seven years, we already stand to lose 40 per cent of our existing generating capacity through the closure of almost all our ageing nuclear power plants and half our major coal and oil-fired power stations (due to the crippling cost of complying with an EU anti-pollution directive).

It is a total mess. The reality is that, thanks to the dithering and wishful thinking of our politicians, it may already be too late to avert that breakdown of our electricity supply which would be one of the most serious disasters Britain has ever faced. And, ironically, no one at present looks more likely to inherit this mess than David Cameron - whose only response to last week' s pie-in-the-sky from Gordon Brown was to say that the Government should have been building all those useless windmills years ago.


British green energy plan 'will force more families into fuel poverty'

More families will be driven into fuel poverty as a push to generate more electricity from "green" sources like wind, wave and solar power sharply increases household fuel bills, the Government has said. Electricity bills could rise by 13 per cent and gas prices could go up by as much as 37 per cent as consumers are made to pay more to subsidise green energy production, ministers said in a new Renewable Energy Strategy. The move away from fossil fuels is likely to cause an increase in energy bills

At current levels, green tariffs make up around 14 per cent of average domestic electricity bills and 3 per cent of average gas bills. Those tariffs will have to increase as ministers bid to wean Britain off fossil fuels like oil, gas and coal. "Our policies to encourage renewable energy deployment in line with our 2020 goals will add further to energy bills," the strategy paper says. "Reflecting some of the costs of tackling climate change through energy prices means that prices more closely reflect the true social, economic and environmental costs of climate change."

By 2020, the document estimates that the full raft of new green energy proposals could increase domestic electricity bills by between 10 per cent and 13 per cent. Gas bills could rise by 18 per cent to 37 per cent. Petrol prices could go up by 4 per cent. Campaigners say that 4 million households are currently in fuel poverty, having to spend 10 per cent or more of their total income on electricity and gas. The Renewable Energy Strategy says: "It is likely that the measures we need to use to increase renewable energy will add to the challenges we face in combating fuel poverty."

Government officials said that the fuel bill increases were based on the assumption that world oil prices will average around $70, roughly half their current level. Were oil prices to stay above that level, the added cost of green energy would be smaller, because of the savings involved in cutting oil use.

John Hutton, the Industry Secretary, said the fuel bill increases were "reasonable and modest" while the cost of doing nothing to cut greenhouse gas emissions would be high. "Is the era of cheap energy over? We all know it is, and that presents us with some pretty stark choices we have to make," he said. "This is the time to make a decisive shift to a low-carbon economy."

Alan Duncan, the Conservative shadow business secretary, endorsed the Government's plan, but said ministers should go further. He said: "After a series of painful and reluctant U-turns, it seems like the Government is at last coming round to our vision of a greener Britain."

The shift to green power will mean 7,000 more wind turbines being built -often in the face of local opposition - across the countryside and around the coastline. The renewable energy strategy was presented by Gordon Brown, who pledged to break Britain's dependence on oil and to convert the country to a greener way of life.

The Prime Minister said the government's commitment to a target of producing 15 per cent of the country's energy from renewable sources by 2020 amounted to a green revolution in the making. "It will be the most dramatic change in our energy policy since the advent of nuclear power," he told an energy conference in London.

Meeting the 15 per cent target will cost the UK economy between œ5 billion and œ6 billion a year, according to Mr Hutton's department. The Government published its energy strategy as Lord Stern, the former Treasury economist who called on the world to spend 1 per cent of its wealth fighting climate change said the price of averting environmental disaster had now doubled to 2 per cent.


Comment from Julian Morris [], Executive Director, International Policy Network, London. See

According to this story in the Telegraph, Stern's estimate of the cost of taking action to reduce carbon emissions was out by 100%.

If the British government proceeds with its various plans to subsidise so-called 'renewables' it would divert vast resources into activities that result in fewer improvements in efficiency and productivity. It may create 'green' jobs but these would be at the expensive of higher value-added white and blue jobs. It would also, as the story notes, lead to increased 'fuel poverty' (i.e. people who are already poor would be forced to spend a higher proportion of their income on fuel and/or risk illness and death by not heating their homes sufficiently).

I also note that today's newspapers carry the sad story of an elderly gentleman who committed suicide after reading that the budget would make him poorer.

I find it difficult to believe that the Tories want to go further! How many jobs do they want to destroy? How much welfare-enhancing growth do they want to prevent? How many poor people do they want to force into fuel poverty or even suicide?


Plans to hit millions of motorists with backdated road tax rises of up to 245 pounds are being axed to head off a Labour revolt next week. Chancellor Alistair Darling has privately assured backbenchers that he will 'fix' the problem in his autumn pre-Budget report. The decision would mark another U-turn following the Government's humiliation over the 10p tax crisis.

Under proposals which will start to kick in next year, nearly 18million motorists - seven out of ten - will pay more to run their cars by 2010, depending on their greenhouse gas emissions. Rebel MPs are unhappy that the increases - sold as an environmental measure - will apply retrospectively to all vehicles bought between 2001 and 2006. Some 48 Labour backbenchers have signed a Commons motion demanding a rethink.

Parts of the vehicle excise duty shake-up will be debated in the Commons on Wednesday and there were fears that the rebels would seize the opportunity to demand the reforms are dumped. But, in a sign that Mr Darling has been forced to review the policy during private meetings, it appeared last night that they will not make a move.

More here

Church of England clergy plan mass exit over women bishops: "More than 1,300 clergy, including 11 serving bishops, have written to the archbishops of Canterbury and York to say that they will defect from the Church of England if women are consecrated bishops. As the wider Anglican Communion fragments over homosexuality, England's established Church is moving towards its own crisis with a crucial vote on women bishops this weekend. In a letter to Rowan Williams and John Sentamu, seen by The Times, the signatories give warning that they will consider leaving the Church if two crucial votes are passed to introduce female bishops. The Church's moderate centre is being pressured as never before by evangelicals opposed to gays, and traditionalists opposed to women's ordination."

Another mad British priority: "Violent assaults and serious antisocial behaviour are lower priorities for councils than stopping people smoking, town hall targets showed yesterday. Despite a government poll showing community safety was voters' overwhelming priority, anti-crime initiatives will not be the main focus of authorities. Details published yesterday by Hazel Blears, the Communities Secretary, set out the targets picked by each local authority - and agreed by her department - to be their future priorities. While performance will be measured across the whole range of 198 indicators, targets will be set only for the 35 chosen as top local concerns".

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