Many MPs raised issues with Ministers about how they will ensure that the extra money voted by Parliament in principle this week to bring down waiting lists will be spent to achieve this end. I myself asked the Minister proposing the NIC rise followed by a new levy what reduction in waiting lists could be secured for the sum in question. Like the Health Ministers themselves he would give no commitment to specific reductions.
The quest for this extra money seems to have come from the new Secretary of State for Health following briefings from the senior management of his department and the NHS. They conjured forecasts of large increases in waiting lists from current levels unless a major new funding package was put in place. I understand the difficulty of making these forecasts, but surely barring a major outbreak of a new virus variant that defeats the vaccinations the waiting lists should be falling as the NHS returns to a more normal working pattern, with the number of serious covid cases well down on the peak before mass vaccination.
Government forecasters seem to specialise in gloom, and have put out some very pessimistic estimates of the spread of the virus which did not come true. This issue of waiting lists should be easier to predict as much of it is in their control.
It is also important to understand why managers and officials think there could be a further surge in waiting list cases if we rely on the £230bn agreed health spend, and then to probe how an extra 4% would make all the difference. If there was more visibility of exactly what the new money would be spent on there could also be a better debate about budget priorities within the existing large agreed totals. We could for example examine the big budget for test and trace and see how that could be reduced as we move to a world where most people are vaccinated and where compliance with it is now low. We could examine the profusion of managers and policy people, of structures and offices that hang heavily above the work of the surgeries and hospitals.
This new team of Health Ministers needs to go through a thorough review of costs and priorities to ensure more money goes to the good medical teams doing the work, and more is spent on acquiring in house additional capacity. The current dependence on locums and temporary medical staff is very expensive.
The NHS also needs to clarify what future use of the private sector it intends to make. Mr Blair started the idea that the NHS would buy capacity in areas like cataract removal from specialist units in the private sector that could achieve good results at affordable prices, leaving NHS main hospitals for more complex tasks. During lockdown the NHS paid to block book a lot of the private capacity to keep some non COVID activities going. How did that work out? Are reports of underuse true?
I am asking the Health Secretary to share more of the detail of how extra money could be used to reduce waiting lists. I am also asking why some senior NHS managers think there is going to be a further bulge in waiting times, given the much lower level of covid cases in hospital now, the progress of vaccinations, and the extra cash allocated to health budgets.
He needs to know how many senior managers and Chief Executives there are now across the public health sector. How is their remuneration aligned with the public interest in high quality care and low waiting lists? Is there a continuing danger of overlap and blurred responsibilities within what is a complex structure?
As the state embarks on recruiting a large number of new Chief Executives for the Integrated Care Boards and for the Integrated Care Partnerships, what reductions if any will there be in the old management architecture this replaces? What arrangements are there to transfer appropriate staff to these new bodies to cut the costs of recruitment and to avoid redundancy costs and disruption to staff?
How will these new Care bodies arrange their purchasing of medical and care services from the NHS Trusts and other health providers? Are the current procurement organisations now withdrawing from contracts with private hospitals, or will they be needing and using more private sector capacity to help reduce waiting lists?
Presumably much of the answer to workload, stress on staff and high waiting lists lies in recruiting additional nurses and doctors to undertake the necessary procedures and treatments. What is the latest view on how many people can pass successfully through training? What action is being taken to encourage the return of already qualified people? How can new technology assist in raising quality and productivity?
The use of temporary and contract staff is expensive and too common. the NHS needs to have more permanent staff members.
The Treasury needs to concentrate on the recovery. Its wish to raise taxes and cut spending is damaging confidence and helping slow down what was a strong recovery.
There is now an urgent need to rescue the recovery. This needs a complete change of attitude and approach, and a new forecasting model to stop the crazily pessimistic forecasts of the OBR.
The Treasury should
1.Set out a new framework for policy based on the current 2% inflation target and debt interest as a percentage of revenue target, dropping the EU state debt targets. The government should add a growth target.
2. Cancel the National Insurance tax hike. We need more jobs not a further tax on jobs.
3. Cut Stamp duty on homes again to add stimulus to a slowing homes market.
4. Stop the further attack on self employment through IR 35
5. Buy more UK goods and services into the public sector instead of so many imports by tweaking procurement rules
6. Commission substantial extra electricity capacity to cut out imports and allow extra power for the electric revolution
7. Speed haulage drivers tests and training
8. Use farming subsidies and rules to promote more food growing – too much is being directed to wilding
9 Do more to make it easy for people to work for themselves, to set up and expand small businesses.
10 State sector to make contract opportunities available to smaller companies.
The danger of associating one tax with one item of spending is people might believe that item of tax paid for that item of spending. This will not be true with the NHS or with social care and the new levy by a very large margin.
According to the Treasury Budget document issued in March they plan to spend £230 billion on health this year, and another £40 bn on social care. The new proposed levy is a bit over 4% of those totals. People ask me if the Council Tax precept for social care will go when the Care Levy comes in. Of course it will not as the Care Levy is only 23% of current social care spending plus the extra from the levy. This assumes they will remove all the Care Levy money from the NHS as currently proposed. The Levy otherwise will pay a smaller percentage of the care budget if some is still needed for waiting lists.
If we wished to have hypothecated taxes to cover the cost of health then it would take all of Income Tax (£198 bn), all of Capital Gains Tax ,all Inheritance Tax, all Stamp Duty and all the Property transaction tax to reach the £230bn figure. Maybe we should rename all these taxes as the Health taxes to show people how income and wealth is currently taxed extensively to pay for healthcare.
If we wanted a tax to hypothecate for social care why not choose the Council Tax which this year is forecast to be that same £40bn figure as the costs of social care.
The debate about waiting lists and about social care needs to start with the current budget figures. The health budget has risen from £166bn for 2019-20 (Treasury forecast in Budget 2018) to £230bn (Budget forecast 2021). It is true the pandemic imposed additional costs and needs on the system, but as these decline we still have much larger budgets than before the pandemic struck. I will look in a future blog at the management issues posed with such large sums of money. I will also return to the issues around social care which I have discussed before.
I voted against for a variety of reasons which I will set out in future blogs. It has been a busy few days trying to expose the spending issues over the NHS, the underlying problems with social care and the true state of the national finances. The media once again did not want to talk about the actual numbers. I was the only MP to start by reminding people how large the current NHS budget is and how big recent increases have been relative to the proposed tax rise.
The government this week moved to honour its Manifesto promise to tighten up on fraud at elections. There have been cases of impersonation, harvesting postal votes by individuals who wish to dictate the voting intention, influencing people to vote in a particular way through undue pressure or power over them, and voting more than once in the same general election by those with more than one residence.
Central to the government’s response is to introduce the need for voter ID at polling stations, to cut out impersonation and vote theft. Controlling postal vote abuse is more difficult, though modern postal votes are addressed directly to the named voter and do include the double envelope system to encourage proper checks on the eligibility to vote and to give people the chance of privacy of their ballot. These precautions do not prevent a residential home manager or a dominant parent or guardian intercepting or influencing someone’s vote in their care.
The government has allowed EU citizens exercising their right to stay here to continue to have a vote in local elections. New arrivals from EU countries will only gain such a right if their country offers a similar right to UK citizens living in their country.
Some express concern about the requirement to show ID to vote. As most other things we do today requires us to prove identity or enter through password controlled systems it is difficult to claim people will find this difficult. As someone who does not welcome more controls and use of passes, I do think voting integrity is crucial. I accept the need to have strong security on work computers for example requiring my ID to enter and would regard the integrity of the vote as very important. There have been enough cases of voter fraud to warrant some action to tighten up. Is this enough?
I do not understand how hypothecating a small part of National Insurance revenue for the NHS and social care works. Assuming the government presses ahead with an increase in National Insurance for next year alongside a dividend tax levy the bulk of the NHS and social care will still be paid for out of general taxation. The government is talking about 8% of the Health and social care budget for the UK being paid for from the levy. Each year presumably there would need to be an additional analysis of how much revenue the extra NI/Care levy would collect alongside a bid for total funds needed to pay for the services concerned, with the danger that the forecast of additional revenues was wrong. Potentially the care sector could get less than planned. I guess then the amount would be topped up out of general taxation, further undermining the case for a small element of pledged tax revenue.
In the past the Treasury has always stood out against a specific tax financing a specific service for good reasons. This time they are assisting a muddle. How can we believe that the extra money going to the NHS from the NI increase will only be temporary? How can we be sure that chosen amount of extra NI will be the right amount for future social care needs? Past evidence suggests these public services always need more than planned. If 1.25% extra on NI would offer a permanent fix someone would have tried it by now.
The government should start with a wide ranging analysis of current social care, then proceed to what extra costs the state should accept. Paying for it is best settled when you know how big the bill will be and what you would get for it. Budgets are meant to be about priorities. If social care needs more maybe some less urgent or desirable expenditures should be discontinued. The Paper issued yesterday tells us to await a White Paper in the autumn on reforming social care, and on the integration of social care with the NHS. These might give us better insight into how much money the government will actually need to offer to the providers. The Paper does not provide the detail of how much people can claim under means tested arrangements to cover social care costs where they have £20,000 to£100,000 of assets. The lifetime cap on care costs is set at £86,000 whatever the person’s wealth.
457 members of the UK military were killed in Afghanistan this century. We have to ask Why did they die?
War is a continuation of diplomacy and politics by violent means. A decent nation only fights a war when talking has failed, when the cause is just and when force is the only language the wrong doers understand. Success lies in fighting fewer wars. Having well resourced and respected armed services is a vital part of our nation’s security and diplomatic weight. Because we have fought victoriously in the past and show resolve in the present we have more chance of negotiating and preserving the peace.
The Falklands war is a perfect example of how a successful war is sometimes necessary and can right an obvious wrong. The unwarranted and illegal invasion of the islands against the wishes of practically every Falkland islander had to be reversed. International diplomacy failed. The Argentinians were unwilling to listen to peace proposals that required they respect the right and wish to the islanders to enjoy self government. A dangerous military campaign was brilliantly executed by UK forces. Peace was re established as soon as the last Argentinians surrendered and has endured ever since. The 258 UK deaths were not in vain. The nation took pride in their achievements. The world is a better place for us showing once again that violent annexation of a country and the termination of its freedoms is unacceptable conduct which will be reversed. We had to do it on our own, as there were divided views amongst nations despite the abuse of force by Argentina.
383,000 of our military lost their lives in the second world war. The vast scale of the death and destruction acts as a warning to the generations that follow to give diplomacy and politics every chance of success in disputes between the great powers. Today technology has delivered even more terrifying abilities to armed forces to kill huge numbers of people and destroy whole cities, making sensible politicians of the best armed countries even more reluctant to resort to war with each other. The nation as a whole does think those who lost their lives between 1939 and 1945 did so for a just cause with an eventual good result. Individual deaths may have resulted from poor planning or bad decisions by the command. More may have died owing to bad intelligence, inadequate force or even friendly fire. The pressures of total war and the ruthless ingenuity of the enemy set each of those difficult deaths into a wider and more understandable context. There is virtual unanimity that there was no feasible negotiated peace available in 1939 that would have prevented the violent annexation of Europe by Germany or would have prevented the genocides which followed.
The relatives and friends of the 457 fallen in Afghanistan need to be reassured that our nation is proud of them too. The immediate cause of NATO’s Afghan war was the unprovoked and shocking attack of terrorists on the United States, with mass civilian casualties. The USA had good intelligence that Afghanistan harboured evil men and the Afghan government was unable to offer assurances that it would find and prosecute the guilty. The early NATO campaign was successful and the government was overthrown. NATO then sought to support the creation of a government for the country chosen in free elections and capable of giving a better life to the many. Economic recovery and better treatment of women and girls followed. As a result many Afghans enjoyed an improved life over the last two decades. The deaths of our troops made that possible. Their achievements should not be forgotten.
The issue for NATO and the politicians is why did the politics fail this year? War is a means to a better end. It is the means to rebase politics which have gone wrong, and to change personnel where government has fallen into evil hands. It is a way of overthrowing dictatorial constitutions and tyrants. This was done in Afghanistan. Unfortunately the decision of President Biden to remove US forces late one night without proper consultation let alone agreement from the Afghan government and allies led to the rapid collapse of democratic government in Afghanistan.The sad scenes of a scrambled exit for the rest of the allies and friends of NATO at Kabul airport led on to triumphant displays of Afghan gunmen showing off captured NATO uniforms and weapons. The return of the Taliban leaves the USA weakened and the NATO allies visibly sidelined. It plunges many in Afghanistan into despair.
Until the withdrawal in recent years NATO had been able to offer limited support and advice to the security forces of the Afghan state, and to keep its own military personnel in the country largely out of harms way. It was a relatively cheap way of defending democracy and basic freedoms in a troubled part of the world and was only undertaken because the elected government wanted NATO to help them keep order. What followed a botched exit by the President was a needless disaster of his own making. None of this should detract from the bravery and good intentions of our forces in the twenty years of supporting the elected Afghan government.
Since 1945 the UK has been involved in a lot of more limited wars. In each case we need to ask why did we use lethal force against others and why did UK service personnel die? We might conclude that we have intervened too often. We should certainly conclude that there have been some bad political and diplomatic failures. War should only be a last resort and should only be used where there does need to be a decisive change which cannot be achieved by talking. There is plenty of collateral damage from warfare. That is elite talk for more people losing their lives and more property and livelihoods being demolished as others disagree violently. We need to get better at talking and persuading, if needs be with realistic threats that we would rather not carry out. People need to know we can and will use force as a last resort as we seek to show them that there are better ways for them as well as us.