Sunak opts to suck it and see

25 Nov

We must be thankful that no-one is forecasting that Government borrowing will rise to record levels this year.  Or Rishi Sunak wouldn’t have been in a position to announce that Government spending will rise at its fastest rate for 15 years.

Apologies for the sarcasm – which isn’t aimed at the Chancellor’s measures, but is meant instead to provide an introduction to the thinking behind them.

One response to a ballooning deficit is to cut the rate of growth of spending.  That’s what the Coalition did after 2010, when the deficit hit seven per cent of GDP.

The Office for Budget Responsibility is forecasting a peak of 19 per this year.  But Sunak’s response is to raise the rate of spending.  Why?

Because in 2010 George Osborne judged the deficit to be structural (he was right), and his successor judges this one to be exceptional (he’s right, too).

It is almost entirely a product of the pandemic and what has followed.  It is in this context that the OBR forecasts the economy to shrink by 11 per cent this year and unemployment to hit 2.6 million next year.

In these circumstances, the Chancellor has found it impossible to produce the four year spending review he hoped for, and has been forced to issue one for a single year instead.

Furthermore, his statement was only one side of the tax and spending coin. Today, we got the spending.  In the Spring, we will get the Budget – and the tax.

Given all this, it will be very odd if Sunak turns up then with large-scale tax rises to raise revenue quickly.  The foundation of his measures today appears to be: suck it and see.

Broadly speaking, the spending package suggests that the Chancellor is going for growth.  That’s the logic of the infrastructure spending, the coming review of regulation, the new northern bank and the enlarged Restart programme.

The Levelling-Up Fund is a classic Treasury exercise in the English centralist tradition, with its central feature of bids from the provinces to Westminster for money.  So it is in a country with relatively few local taxes.

On that point, Sunak announced “extra flexibility for Council Tax and Adult Social Care precept”.  Local authorities will like that, council taxpayers not so much.

It’s worth stressing that the OBR’s forecasts, like all such animals, shouldn’t be taken too seriously.  Our columnist Ryan Bourne debunked its record on this site earlier this week.

If you walk down the sunny side of the street, you will smack your lips at the thought of a Roaring Twenties effect, as employment recovers, consumers spend, the hospitality sector booms and people pile into holidays abroad.

And it may be that post-Covid changes even out for the better, with a shift in activity and spending from city centres to the suburbs and countryside, together with music, art, theatre and all the rest of it.

That might not be such a bad things for towns and their centres, at which the new Levelling Up Fund is partly aimed.  Our columnist James Frayne believes they are a core concern for provincial voters, and government listens to him.

If on the other hand you stick to the shady side, you will point to the economic equivalent of Long Covid: fearsome economic and social bills for damaged mental health, postponed operations, lost educational opportunities.

All that is a big minus for levelling-up – because it’s the disabled, poor and disadvantaged who have been hit hardest by restrictions and lockdowns, especially if they work in the private sector.

The background in recent years is not encouraging.  Since the financial crash exploded, we haven’t grown at more than 2.6 per cent a year.  That suggests recovery may be sticky.

Sunak’s persuasive manner, grip of detail and spare eloquence have served him well during this crisis.  Others holding his post would not have survived roughly ten major finance annoucements in less than a year.

It’s not as though he hasn’t sometimes had to recast his plans – as in October, when he pumped more money into his Job Support Scheme.

And if the economics of his strategy are straightforward enough, its politics was sometimes a bit odd.  If the Government’s overall plan in the short-term is expansionary, why raise the minimum wage but curb public sector pay?

If spending on nearly everything else is rising, why crack down on the 0.7 per cent aid spend?  Doing so because you think aid is wasted or the target is wasteful is one thing.

But that wasn’t the basis of Sunak’s decision – since, after all, he said that the Government intends to return to 0.7 per cent “when the fiscal situation allows”.

The Chancellor also left a big unresolved question hanging in the air.  What will the Government do about the Universal Credit uplift?  Will it be extended or not?

The sense of a statement with contradictory messages was picked up Rob Covile of the Centre for Policy Studies.  (The Treasury would do well when the Budget approaches to look at its supply side ideas.)

“Feels slightly like Treasury couldn’t decide whether the message was ‘tighten belts’ or ‘we’re still spending’,” he tweeted. “So we’re getting two or three minutes of each in turn.”

That first element in the Chancellor’s statement, plus the OBR’s horrid short-term forecasts, comes at a bad time for the Government.

For tomorrow, the toughened tiering details are announced. Lots of Conservative MPs won’t like them.  The detail of which tiers apply in which areas will be published, too.  Many Tory MPs will like those even less.

Graham Brady, Steve Baker, Mark Harper, and the Covid Recovery Group will say that the economic damage of restrictions is so severe that the Commons should not vote for more – at least, without an impact assessment.

They may not be alone.  “These measures may be a short-term strategy, but they cannot be a long-term one,” Jeremy Wright declared in the Commons during the recent debate on the lockdown regulations.

He and Edward Timpson (another ex-Minister) plus other MPs backed the Government but, sounded a cautionary note.

Will the prospect of vaccines be sufficient to rally the doubters round?  Or will they take a leaf from the book of Theresa May, who savaged the regulations during the same debate?

We shall see – but Ministers are not helping themselves by dodging requests for that impact assessment, urged by this site and others, and the subject of a dogged campaign by Mel Stride, Chair of the Treasury Select Committee.

All in all, Sunak is shaping up to go for growth.  Good for him.  Nonetheless, he must watch and wait to see how and when the economy rebounds.  Brady and company are less patient.

Dean Godson: It’s easier for the right to a left on economics than for the left to move right on culture. That’s a plus for Johnson.

21 Nov

Dean Godson is the Director of Policy Exchange.

“You have limited time, limited capacity, and limited choices. Where does your focus lie?” asks Rachel Wolf on this site last week. Well, the Conservative Party has been walking and chewing gum since Disraeli’s 1867 Reform Act — and there is no reason why the “reset” triggered by the departure of Dominic Cummings should change that.

Representing a critical mass of both the prosperous and the “Just About Managing” classes and parts of the country is what all successful political parties do in democracies. Since the Tory party became the party of Brexit and expanded – or maybe one should say rediscovered parts of its working class base – it is certainly true that the heterogenous coalition which it represents has spoken with a somewhat different accent.

Indeed, a case can be made that the part of the political class that ascended to power after December 2019 represents a significant break with all governments since the fall of Margaret Thatcher. The governments of John Major, Tony Blair, Gordon Brown, David Cameron and Theresa May (though less so the latter) tended to put global integration before national sovereignty, the metropolitan before the provincial, higher education before further education, trains and planes before buses, diversity before cohesion, the cognitive classes before the artisanal ones.

Their version of the national interest broadly reflected the priorities of what my colleague David Goodhart, who was interviewed recently by this site, has called the people who see the world from Anywhere. And in his most recent book Head, Hand Heart, he describes a narrowing definition of a successful life, as seen by Anywhere Britain, based around academic success, a university education and entry into high-status professional employment. This is the world of the big cities, the university towns and much of the middle and upper public sector, (and certainly of wide swathes of the senior civil service which were at daggers drawn with Dominic Cummings).

But what of that part of the population that cannot achieve or does not want to achieve this version of success? They still want recognition, and to feel able to contribute to the national story and the Brexit vote provided the opportunity for many of them to say ‘no’ to much of that governing class consensus.

The Vote Leave strand of the Johnson Government sought to represent and appeal to this part of the electorate – summed up in the phrase “Levelling up” – in a way that no government, let alone a Conservative government, has done for decades. That has, unavoidably, created tensions with many powerful interests and beliefs, including inside the Tory Party itself, many of which came to be focused on the pugnacious personality of Dominic Cummings.

A more emollient tone can be struck – but to abandon what was termed “Erdington modernisation” (after Nick Timothy’s Birmingham roots) and return to the necessary but not sufficient Notting Hill modernisation (in which the party made its peace with much of modern liberalism) is now very hard.

This is the case for electoral reasons as much as any other – with both Keir Starmer and Nigel Farage both praying for a return to Cameron-Osborne era Conservatism with its implicit assumption that the common good can be achieved through a kind of trickle-down from the most successful and dynamic parts of our society.

There are other reasons for thinking that it would be foolish to switch back now. Politics for most of the post-war period has been dominated by economics. And, of course, a thriving economy is still a sine qua non for any government. But economics is a means not an end, and the economistic bias of the Anywheres gave us the failed cost-benefit analysis of the Remain campaign.

Today’s much higher profile for the security and identity cultural issues ought to be a boon to the centre-right because, as has been pointed out, it is easier for the right to move a bit to the left on economics (as it certainly has done) than for the left to move right on cultural issues (as Starmer would no doubt like to do, but will find his path blocked).

This does not require an aggressive culture war from the right. The cultural offensive has been coming mainly from the left – as exemplified by the controversies over statues and the decolonisation of museums. The right needs to stand up for common sense, and for the large majority who accept the equalities of modern liberalism but do not want their sensibilities constantly undermined.

Conservatives should be the party of value diversity. Go back to the 1950s and the country was often dominated by a conformist, traditional culture that stunted the lives of many people and often punished those who deviated. Over many decades, much higher levels of choice and freedom for women and minorities of various kinds have been achieved.

Part of the Left now wants to impose a degree of progressive conformity comparable to the traditional conformity of earlier decades. Tolerance and pluralism should be the watchwords in these matters — with a strong bed-rock of rights and anti-discrimination legislation, but also an understanding that rights and values often clash and the ratchet should not only turn in a progressive direction.

That all said, walking and chewing gum is possible, and there is space, post-Cummings, for a new tone and a new stress on policy bridges that seek common ground between Anywhere and Somewhere priorities.

The green industrial revolution is clearly one of those policy areas, and should not be seen as a soft bourgeois indulgence. As the Prime Minister said on Tuesday, it is places like Teesside, Port Talbot and Merseyside that are now centres of green technology and jobs. Ben Houchen, the mayor of Tees Valley, underlined the same point in the introduction to Policy Exchange’s recent report on The Future of the North Sea, and on ConservativeHome earlier this week. Research we will soon be publishing on redesigning the national grid should also generate many good, skilled jobs in areas that are sometimes seen as “left behind”.

The re-set seems more likely to be a milder form of reboot. Without Cummings, some of the urgency will go out of parts of the recent agenda, particularly the machinery of government and data in government focus. But many of the priorities of the new conservatism—Brexit, levelling up, higher spending on the NHS and police, social care, boosting further education, immigration reform, restoring some bustle and pride to Britain’s often unloved towns—are owned by a broad range of the people that matter.

The Red Wall voters are likely to prove more complex beasts than in the Vote Leave or Remain caricatures – and no political strategy can focus too much on just one slice of the population but without producing visible, tangible improvements to the lives of people in places like Stoke and Leigh before the next election the Conservatives will not be returned in 2024.

Jude D’Alesio: We need a new social care settlement, but a copy of the NHS is not the answer

14 Nov

Jude D’Alesio is one of the youngest councillors in Britain, serving on Long Ashton Parish Council in North Somerset.

Losing my part-time job as hog roaster was not how I envisaged the beginning of my Easter holidays. Instead, lockdown created a surge the demand for care assistant roles in my home city of Cardiff.

I could lie to you and say that this was the job I had always dreamed of having, but truthfully I was not prepared to play my PlayStation for a whole summer and needed an activity to bridge the gap to until I resumed university in September.

However, I was not prepared for how much it would teach me about the politics of social care. Indeed, learning everything from how to wake a resident in the morning, how to talk to a person with dementia, how to feed someone in their bed, and how to detect when they about to fall over, was a world apart from my law degree.

But if I learnt one thing as a care worker during Covid-19, it is that we need a new settlement for social care in Britain.

The Prime Minister and the Chancellor were swift in their response to the pandemic in the industry, boosting funding for councils as well as pledging that the promise to do ‘whatever it takes’ applies as much to social care as the NHS. So far, the pandemic has ensured that this valiant defence of social care is replacing the previous treatment of care as the poor cousin of the NHS.

Ensuring that the most vulnerable in society are safeguarded is a noble aim, though Gordon Brown’s proposed ‘death tax’ in 2010 reminds us that a realistic solution is unlikely to emerge from the left. Contrary to what some may think, I found that many of the residents under my care, no matter how mentally impaired, were concerned about their finances. Once, I was asked by a resident to go the bank (unlikely to occur at 2am on a Sunday) so that they could pay for their meals, despite them being prepaid by the family. Elderly residents worrying about their care is funded should not be commonplace in Britain.

It must be acknowledged that care homes were only able to focus all their efforts on beating coronavirus due to much of the normal care bureaucracy, such as routine Care Quality Commission inspections, being abandoned. I quickly learnt that ‘inspections’ was considered a dirty word among my colleagues, who told ironic stories of being distracted all day by inspectors who were, unsurprisingly, concerned with completing their tick box exercises. If this fails to renew the Government’s impetus to cut stifling bureaucracy following the pandemic, I know not what will.

Another benefit which emerged in the industry was the rapidity with which elderly patients were discharged from hospital into care homes. By the end of my stint as a care worker, I learnt that it was not uncommon for a new resident to be arriving every week from hospital, and given that the inert process of discharging elderly patients to care homes was a bane for policymakers, I hope that this new vigour sticks.

There is a paradigm throughout social care of focusing incessantly on negative metrics resulting from regulation: weight loss, bruises and aggressive behaviour, for example. Care homes must become less custodial and prioritise quality of life and happiness, not adopt a box-ticking exercise.

Conscious of how a large portion of my work was spent filling in checklists, I soon learnt why many residents soon spiral into depression upon being admitted to a home. As such, I prioritised engaging in more interpersonal interactions with these people, who often had incredible stories from their childhood and profession – not to mention reassuring Conservative views!

Care homes have seen residency rates fall dramatically, with a simultaneous need to make them safeguard against COVID-19 which has squeezed profit margins (by the end of summer the place was half-empty, with the occupancy rate dropping every week).This coincidence of underlying financial weakness, falling revenues and rising costs means that many homes are on the precipice of closure. However, there is an understandable reluctance by the Treasury to countenance an expansion in the scope of the state.

A report by the Centre for Social Justice concluded that countries where the state has provided full free social care without restrictions have seen costs spiral unsustainably, forcing them to restrict eligibility and cut back services. Establishing a national care service is, unfortunately, not an option.

So, this is what I propose: a basic level of social care for everyone, funded nationally by taxation, but people buy out-of-pocket top-ups to purchase private insurance policies to cover additional care – a model backed by the CSJ. This will end the injustice of some having to sell their homes to finance their care while reforming the structure of incentives to encourage private investment.

Covid-19 has provided the impetus to reform our care system, and if I learnt one thing as a carer it is that change is needed. I hope I am not proved wrong in saying that the energy from Downing Street thus far signals that we have a government which will get social care done

Raghib Ali: The Government needs a Plan B for Covid-19, lives and livelihoods. Here’s how one would work.

22 Oct

Dr Raghib Ali is an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Visiting Research Fellow of the Department of Population Health, University of Oxford.

Last month, I described on this site what I expected the likely trajectory of the second wave to be; explained why a certain level of suppression was needed to enable the NHS to keep running all services running to prevent non-COVID health harms; and why that should not be achieved through more lockdowns, since the Government’s own cost benefit analysis showed it caused greater overall long-term health harm.

Since then, there have been increasingly pubic divisions between both scientists and politicians as to the best way forward over the coming months with opposing declarations and memorandums.  Some say current restrictions go too far, others not far enough – with the Government left in an almost impossible position of choosing the least worst option.

Today, I will briefly review the main strategies that have been proposed – herd immunity/focused protection (Great Barrington Declaration, GBD); further suppression/test & trace (John Snow Memorandum, JSM); the current tier system with targeted restrictions; and a potential alternative way forward.

In my last article, I outlined three criteria that any strategy / intervention should be judged by:

i) the evidence for effectiveness,

ii) whether a mandatory approach produces better outcomes than a voluntary one, and

iii) most importantly, that they produce less overall harm.

And today, I add a fourth – compliance – because all measures are only effective if a high enough proportion of people comply with them.

The Great Barrington Declaration

Having consistently highlighted the health harms of lockdown since May, I did of course welcome the GBD’s emphasis on the many harms of lockdown – particularly in developing countries without welfare states – where lockdowns are even more likely to cause overall health harm.

However, a declaration is not a policy and there are still too many unanswered / unanswerable questions which have been highlighted by many others.

Although I fully agree on the need to focus protection on care homes & hospitals, I am not yet convinced that it is feasible to shield the very large numbers of vulnerable people in the community while Covid-19 transmission is high (especially for those who live in multigenerational households).

Also, the number of ‘non-vulnerable’ who would be symptomatic and hospitalised in the coming three to six months (about 50 per cent of COVID admissions are currently aged 18- 64) would make it very difficult to maintain all NHS services – there is simply not enough spare capacity (particularly of staff.) And no country has successfully followed a herd immunity strategy.

It also does not currently have public support (more than 2:1 oppose it) which would be essential in maintaining compliance with shielding for the vulnerable; and in persuading the less-vulnerable to be exposed by returning to normal life.

Finally, its advocates have not shown that it will cause less overall harm which is, of course, the key overall metric it should be judged by.

The John Snow memorandum

In response to the GBD, the JSM was released. I understand the rationale of those who advocate a second (so-called ‘circuit-breaker’) national lockdown who believe that is better to have a shorter lockdown now than a longer one later – which may well be true – but this is not the key question, which should be: is it less harmful than not having one at all?

The limitations and harms of lockdowns have been well documented and I will only add a few points.

There is insufficient evidence that a two week lockdown will achieve its aims (Israel’s second lockdown has already lasted four weeks) and it may not be possible to lift it after two weeks if cases are still rising. And this strategy may just lead to a cycle of lockdowns which is not sustainable.

Lockdowns are only effective if they are complied with (Israel had much lowers levels of compliance in their second lockdown) and, even with current restrictions in the UK, compliance is lower than it was during lockdown and there is no guarantee it will be high enough to be effective.

The models only show that a lockdown may reduce Covid-19 deaths, but these have not modelled the number of non-Covid lives that will be lost or adverse health effects from other causes.

Although the intention of the circuit breaker is to buy time to get Test &Trace (T&T) back on track and ensure the NHS is prepared, it is hard to see how two weeks would make much difference when the NHS has had months to prepare.

T&T is of course an essential part of the solution but, again, there is insufficient evidence that we will ever be able to control the virus through T&T – we tried this over the summer when virus levels were almost zero after one of the longest lockdowns in Europe and it hasn’t worked here – or in the majority of countries in Europe.

It is also not true to say that ‘the only thing that works is lockdowns’ – social distancing and sel -isolation before lockdown here was bringing R down, and Sweden has showed it is possible to overcome a first wave without one – which I will return to later.

Finally, although public support for a two week lockdown is currently high, this would change if it was made clear that it could be 4 or 6 weeks or that it may well cause more long term health harm than benefit.

I know and respect many of the scientists supporting both positions and know they genuinely believe their strategy will cause the least overall harm, but I have not signed either the GBD or JSM. Neither adequately acknowledges the limitations and harms of their approaches or the uncertainties of the evidence – and both are overly confident in their assessment of their effectiveness.

The Government’s three-tier system

I still think the current gGvernment strategy of suppression to keep cases low enough to maintain all NHS services and minimise non-Covid health harms while trying to protect education and jobs is a reasonable compromise. Furthermore, if virus levels get too high, fear increases and people don’t come to hospital, don’t go out and the economy suffers, etc.

I certainly support the targeting restrictions based on the local level of cases as opposed to blanket national ones. I find it hard to understand how it can be possibly be fairer to destroy jobs and businesses all over the country including in areas where hospitalisations are extremely low than to target restrictions on those areas where they are highest and the NHS is under pressure. This should not be a political issue, or North vs. South – it’s just common sense.

We can only get through this crisis by supporting each other, and by keeping the economy open in as many places as possible, we can help fund businesses and jobs in those areas that are forced to temporarily close until the pressure on the NHS subsides.

There is also evidence that the current measures are working – R is stabilising (or even falling) in most regions at about half the level of the first wave, and the NHS is not being overwhelmed. However, they have not yet bought R down below one, and hospitalisations and deaths are still  rising.

The key problem appears to be compliance, and we need to focus more on how we can improve compliance with existing restrictions rather than increasing restrictions. After all, the purpose of restrictions (& lockdowns) is purely to enforce social distancing. We urgently need to analyse levels of compliance by local area and to understand what is driving lack of compliance.

For example, despite good intentions, only 20 per cent of those required to self-isolate are doing so, and it may be that financial incentives may be more effective in sustaining compliance with testing and self-isolation (e.g. paying people to self-isolate, as in Germany and Sweden).

Some people also think the measures aren’t working and so say, ‘What’s the point?”, but this is not true, which needs to be stressed.

So think it is reasonable for the Government to maintain its current strategy for three more weeks to see the effectiveness of the Tier Two and Three restrictions and devolved nations ‘circuit-breakers’.

A potential Plan B

However, we also need a Plan B to get us to Spring – and potentially longer if vaccines / treatments / mass testing are not as effective as hoped.

I would therefore ask the Government to consider an alternative strategy which may cause less overall harm based on the Swedish approach, but with much better protection of the vulnerable, especially in care homes. This is now much more achievable than in the first wave – because cases are lower, testing and PPE are more available. Individual risk calculators will now also  enable, smarter, voluntary shielding of the community vulnerable.

The key point is that Sweden has shown that it is possible to suppress the virus and get over their first wave (and so far control their second wave) without a national lockdown; without reaching herd immunity and without an effective T&T system. And while keeping schools and businesses open – and so reducing overall harms.

The Swedish approach has been widely misunderstood – the official government strategy is ‘to limit the spread of infection in the country and by doing so, to relieve pressure on the health care system and protect people’s lives, health and jobs.’

And as its Chief Epidemiologist, Dr Anders Tegnell, has said, Sweden is not trying to reach herd immunity (and has not achieved it) and it did not encourage the non-vulnerable to return to normal life. Indeed, its government is strongly encouraged social distancing, reducing social contacts, plus th use of public transport and working from home).

It has also introduce many other measures (i.e: closing universities, table-service only in restaurants, limited gatherings to 50 people.Tegnell has described the policy as a ‘voluntary lockdown’ – and generally the levels of compliance have been very high.

The Government has stressed personal responsibility and trusting the public with simple, consistent, public health messaging and tried to build public consensus and trust.

Of course, there are differences between Sweden and the UK, and there is no guarantee that its approach would work here, but the principles are still valid. The Sweden model is also not a cost-free option – and may lead to more Covid-19 deaths in the short term than would otherwise have been the case – but that is not the key metric, which is whether the strategy will lead to the least overall health harm in the long term.

The key to any successful strategy is sustainable compliance – and it must therefore have public trust and confidence. Open debate is important but, as I wrote in June, ongoing divisions lead to both fear and complacency, undermine public confidence and compliance – and can cost lives and livelihoods.

We therefore need doctors, scientists, and politicians to get behind the same overall strategy and I think this will only be possible if we can show which one causes the least overall harm.

The Government should therefore immediately bring together doctors, scientists and economists to conduct a comprehensive cost-benefit analysis of these four options (similar to the one they have already conducted) and come to a consensus – which should then be shared with the public and other scientists.

I have made my own assessment, but I neither have access to all the data nor a monopoly on wisdom and so am happy to accept whichever option comes out best – and hope others will do the same.

I end with the same conclusion as in June: ‘Finally, of course we are not primarily ‘pro- or anti- lockdowners’ – we are all ‘pro-protecting lives and livelihoods’ and wanting to recover from this crisis as quickly as possible. And so, we must put aside our differences, compromise and come together in the national interest. ‘A house divided against itself cannot stand.’

Ed Jones: The Government must grasp the nettle of social care reform

14 Oct

Ed Jones is a healthcare consultant. He was Chief of Staff to Jeremy Hunt, and Special Adviser at the Department of Health and Social Care from 2013-2018.

Another party conference and another promise to sort out social care funding. I drafted a few of those promises myself, all of which sadly proved empty.

The Prime Minister must now break the deadlock and set down a new social care settlement as a cornerstone of his “new Jerusalem”. But it won’t happen until government confronts the political choices previous leaders have ducked.

This is the opposite of the usual pleas from those of us who self-identify as centrists and policy wonks. Self-reported experts and moderates normally demand “evidenced based policy” in all things. We tend to criticise decisions motivated by naked politics or crude ideology.

But there are some issues which will only be resolved if you start with the politics, and the urgent need to sort sustainable social care funding is one of these. We failed in my time in government because we never truly faced up to the stark political choice needed, or we were unwilling to see it through.

Hearing talk about “cross party consensus” and “removing the politics” makes me worry that this Government hasn’t faced up either.

Finding more funding, from somewhere, is a moral and economic priority. The evidence on this is clear. Moreover, it is also about human dignity. But the possible solutions (the shape of the offer) and the question of funding (who pays for it) are intensely political choices and it does nobody any good to pretend otherwise.

My own years in government saw an inability or unwillingness to confront those choices. Endless options appraisals and reviews, expert contributions, industry consultations, and academic exercises were undertaken but we never formed a view, with conviction, about who we were actually willing to upset in order to get this sorted.

This is one area where a Prime Minister has to start with a clear political choice, and work back from that to the policy mechanism which delivers on it. Simply passing around the same slide decks and evidence reviews which have circulated through Whitehall for more than ten years, expecting a new and easier way through to emerge, is futile. A political call must be taken. One political constituency will have to win out over another.

This has proved particularly problematic for Conservative governments as the stark political choices divide the party. In the memorable “trilats” we had with the former Prime Minister and Chancellor to agree a resolution for health and care funding, Theresa May and Philip Hammond’s views neatly exposed this divide. Hammond argued the purpose of saving and building assets in life (whether in cash, property or other forms) was to be self-sufficient in old age. Treasury officials pointed to the nearly half a trillion pounds amassed in the property assets of older people.

In contrast May, burned by the failure to deliver the original 2017 manifesto reforms on social care, argued that hardworking people who paid taxes all their lives and did the right thing did not deserve to lose the value in their homes. Both of these positions have a conservative ethos in some respects, but they are contradictory. Meanwhile the Treasury rightly oppose simply adding to government spending/debt, and the public oppose new taxes on income, especially if those taxes are targeted at particular age groups.

The 2019 election adds a further complication perhaps: that the Red Wall electorate, in areas where housing stock is less valuable, has less to gain from the Dilnot-style cap which many in government had recently favoured. Furthermore, the impact of Covid-19 will have right prompted more fundamental thoughts in Government about reform of the whole sector.

Indeed, a sad consequence of our unwillingness to confront the choice on funding is the failure to significantly progress the wider reform agenda, from technology adoption to care quality and consumer rights. Our 2018 Green Paper, never published, outlined reforms in these areas but was held up by our failure to get collective agreement about the one chapter on funding.

So, enough of wheeling in the same weary academics and experts, asking them to repeat the assessments they have given to all the previous politicians they saw come and go. Let’s draw a line under forlorn attempts to seek cross-party agreement with the Opposition (the clue is in the name). The definition of political leadership is to strike out with conviction and make a choice when the options are unenviable and the path ahead is dimly lit, and then to take people with you as best you can.

This Prime Minister is better equipped for the task than many others. But we have yet to see this, which can only mean that either the Government hasn’t yet faced up to the choice, or they don’t think the public is ready to hear it.

Gareth Lyon: Reforming social care must include an increase in the supply of accommodation. More choice is needed.

7 Oct

Gareth Lyon is the Head of Policy and Communications at the Associated Retirement Community Operators. He is a former councillor in Rushmoor and the Chairman of the Aldershot and North Hants Conservative Association.

Whilst the recently announced delay to the Government’s proposals on reforming social care will come as a big disappointment to a sector which has been lacking in political and policy direction for a long time, there may be a silver lining if this is used as an opportunity to reframe the debate away from the demand side hole it is stuck in right now – ie, how care is to be funded. Important though that is, we must also look at the opportunities presented by supply-side reform and how care is delivered.

Of course social care is not sufficiently well funded in this country and something needs to be done about it. Part of the solution may well lie though, in structuring services so that people actually choose to fund their own care by buying in to a wider package including lifestyle and wellness offerings as well as convenience and the ability to avoid financial hassle and risk.

This is certainly one of the lessons the UK can learn from Australia and New Zealand where the shape of the care system is very different to over here, and where far greater choice of options exists.

A major feature of the care landscape in those countries is retirement villages, known in the UK by a variety of terms including Extra Care and Retirement Communities. They combine the benefits of older people being able to live in a home of their own (with every resident owning or renting a flat or bungalow) and the security of 24-hour onsite staffing, the provision of high quality onsite care, and the availability of onsite facilities such as restaurants, gyms, allotments, bars, swimming pools etc.

Older people choose to move into a retirement community because of these advantages, the social benefits of having a community available onsite, and the well documented health and wellness advantages which make it much less likely that they will end up in a care home or residential home.

Retirement communities are fundamentally different to the sheltered housing or retirement flats we are familiar with in this country – not just because of the provision of care and facilities, but also because of how they operate – the developers not just building out and moving on, but staying onsite and providing these services funded by service charges and fees tied to the value of the property when people come to selling on.

The result of this is that the care which is provided onsite is subsidised out of the fees which people voluntarily choose to pay. Care which reduces the strain on the wider social care system and which would not otherwise have received this funding.

There is a clear lesson to be learned here – that contrary to all public policy presumptions at the moment, people need not be forced to pay for care. By providing the right package of services people are prepared to pay for it themselves.

A very high proportion of older people own their own homes and are at least theoretically in a position to take up this opportunity. For those who do not, the UK already has a well respected affordable housing version of retirement communities, which is well placed to expand and form one of the centre pieces of a new system.

As things stand, in the UK our retirement communities sector provides about a tenth of the capacity per head of population that the New Zealand and Australian sectors do. For this sector to play a role there will need to be significant growth – and fast.

It is interesting that investors appear to have detected the opportunity presented by new forms of provision before policymakers have. Major long-term capital investors such as Legal & General, AXA, Schroders, and Bupa have all made and are making investments in the nascent UK retirement community sector.

It is however clear that, as with any new sector, new and adapted regulation, specifically in relation to planning, consumer protection, and leases is needed. Early indications are that the Government understands that something needs to be done but has not yet found the administrative capacity to do it.

Yet compared to the much more intractable challenges of securing consensus on funding reform for the wider social care system, and with several months set to elapse before that fight even begins, there is certainly something to be said for the Government dedicating at least some of its energies to the supply side options already presenting themselves now.

Covid. Mass lockdowns v a Swedish option is a flawed choice. But if Ministers can’t make mass testing work, it’s the one we’ll have.

23 Sep

Perhaps Boris Johnson’s new plan will succeed.  Maybe factories and building sites will stay open, plus the retail and hospitality sectors, as well as universities and (crucially) schools.  Perhaps the move back from offices to schools will help keep Coronavirus on public transport under control.  If so, the firewall that Ministers want to build between work and home will stand.

In both, there is to be a new stress on compulsion.  At work, this will largely be limited to retail and hospitality, where the Government’s guidelines will become legal obligations, and the requirement to wear face masks will be extended.  At home, in family life and in leisure time, there is the rule of six, smaller weddings, restricted sports events, 10pm curfew for pubs.

All this will be enabled and enforced by Covid marshalls, higher fines and penalties, and not only the police but (the Prime Minister hinted) the army – and big lockdowns that cover groups of local authority areas.   As we say, maybe this plan will work, but we doubt it.  The most likely course ahead is a patchy schools’ service, which will drag parents away from work, plus a further clampdown on first hospitality and then retail.

Johnson suggested as much yesterday: “we reserve the right to deploy greater fire power, with significantly greater restrictions”, he told the Commons.  And although the plan’s outline is clear, its details are contested.  In that respect, we are where we were before: the Department of Health stresses tackling the virus, the Treasury supporting the economy.

Rishi Sunak appears to have staved off a more extensive crackdown on hospitality – for the moment, anyway – but the Government’s internal haggling and bargaining points to an uncomfortable truth.  The clampdown seems too extensive to satisfy a growing lobby within the Conservative Parliamentary Party, but not extensive enough to satisfy a significant chunk of the Government’s scientific advisers.

So there is a danger that it will fall between two stools, and be revised soon anyway.  In weighing where we are, it would be easy to vanish down the rabbit hole of detail (asking why, for example, it is considered safe to drink in pubs and drink in restaurants before 10pm but not afterwards).  Instead, we should stand back from yesterday’s change of tack, and think about the big picture.

When Covid-19 first gathered pace, we were told that a lockdown was necessary to save the NHS.  That is a clear goal – and an understandable one, since the public would not have tolerated TV pictures of overwhelmed hospitals, with ambulances incapable of discharging patients and others unable to get treatment at all, so dying at home without any palliative care.

After the original lockdown was eased, the emphasis shifted from “save the NHS” to “control the virus”.  The Prime Minister said yesterday that we should “safeguard the NHS”, but it wasn’t clear if the Government believes the rising caseload is a serious threat to it.  It appears that Ministers and their advisers are aiming, rather, to suppress the virus altogether.

That raises obvious questions about trade-offs – between driving down the virus and other healthcare objectives, and between lives and livelihoods: that’s to say, the wider workings of the economy which produces the growth, jobs and wealth without which the NHS would be unable to function in the first place.  We asked in May for the Government to publish a worst-case scenario for the service, and if it there is one we haven’t seen it.

Nor is it clear what those healthcare gains and losses have been so far.  Obviously, trying to calculate them is like trying to take a still photo of a moving person, but the effort must surely be made.  In its absence, opinion among Ministers and backbenchers is dividing, with a growing number – we can’t be sure of what it is – favouring a stress on voluntarism rather than compulsion: the Sweden option.

We believe that a choice between Sweden and lockdowns is a false one, for a simple reason.  Why would we model our response on the country with the eleventh highest number of deaths per head (Sweden) – only three places behind the UK – rather than one with the forty-fourth (Germany)?  We concede at once that these international comparisons are fraught with problems.

But that’s an issue for those who favour a Swedish-syle approach as much as those who support a German one.  In any event, as a country with the second largest economy in Europe, we are more easily considered alongside the country with the first – another, furthermore, with a relatively large population.  The fundamental difference between Sweden and Germany is the stress on testing.

The Government has handled some aspects of Covid-19 well (building the Nightingales) and some badly (failing to protect care homes).  Johnson will be consoled this morning by the fact that, if the initial polls are right, elite opinion on the Right may lean towards Sweden but the voters still support lockdown – though a growing and articulate minority do not, and exaggerated public fear of the extent of the virus brings problems in its wake,

Undoubtedly, however, Government communications have been more than a bit of a shambles – ever since, significantly, Ministers moved off the message of protecting the NHS.  In July, the Prime Minister was hoping for “a more significant return to normality from November…possibly in time for Christmas”.   Instead, we have a significant move from normality in September, which is set to last for six months.

We appreciate that all governments have made mistakes in handling the developing unknown of the virus, here and abroad.  But, frankly, too much hope has been invested in vaccines; too little stress has been placed on living with the virus; too much has been allowed to “the science” (with the latest dubious stress from the chief scientists on worst-case scenarios)  – and too much of the debate has swung between two unworkable extremes.

Big lockdowns of whole cities or metropolitan areas, which could well end up as a national one in effect, are not a solution, since they bring with them harmful outcomes and have an unclear objective.  Mass voluntarism might well be less damaging, but Sweden’s experience suggests it would bring higher death numbers with it – along with voter resistance, openings for Keir Starmer, and the canard that “the Tories don’t care about saving lives”.

Instead, Johnson needs to set clear testing targets, stick to them build on progress made, and stay on piste.  We are well aware of the problems. The UK doen’t have the laboratory capacity it needs, so scaling it up takes time.  Testing finds more cases, thus feeding public alarm. There are false positives (and negatives).  Some people will need tests won’t take them.  Others who take them don’t need them – or at any rate, need them less than, say, teachers.

Care homes have consumed a lot of the tests; the return of schools has had an impact; an earlier-than-expected upswing in cases has caught the authorities out.  Furthermore, we still await a workable NHS app, our health system is over-centralised, and effective tracing remains a work in progress.  But more tests, quick tracing, quarantine and mini-shutdowns if necessary (not the closure of whole cities and metropolitan areas) are the best-in-class solution.

It is one that would minimise the debate about trade-offs, since the economy would be able to return to nearer normal.  If it isn’t delivered, watch for pressure on the Chancellor for more furlough, more subsidies, more loans, and a shorter spending review – with higher taxes and lower spending coming later down the line.  And for the options to harden to two flawed extremes.

Dean Russell: As a volunteer in my local hospital, I saw at first hand the damage done by NHS fearmongering

1 Sep

Dean Russell is the MP for Watford and a member of the Health & Social Care Select Committee.

Concurrent with Matt Hancock’s recent announcement about the creation of the National Institute of Public Health (NIPH) came the usual reactionary political cries that this means the NHS is under threat of privatisation.

The sad truth is that whilst politicians are repeating old myths like a broken record, they once again fail to look at the actual record of the NHS under the Conservatives since its inception in 1948; in doing so, they are causing genuine distress to those who are most vulnerable.

I understand that old habits die hard when it comes to political fearmongering; however, in the efforts to win votes through these repeated false claims, they are only hurting the very people they claim to protect – health and social care workers.

The problem with these entrenched and unfounded claims around NHS privatisation is that politicians make it difficult to be open about where issues exist within these large institutions, which, in turn, means that front line staff are the worst hit.

Just this week, I was fortunate to spend a day with St John Ambulance and meet hospital staff who they had been volunteering alongside during the crisis. They all made the point that that pre-Covid the levels of red tape and bureaucracy needed to enable St John Ambulance to help volunteer on wards would have been too immense ever to see it happen.

The nature of the Covid crisis enabled the NHS to be allowed to utilise the assets that an organisation like St John Ambulance teams can provide. This additional workforce during such an unprecedented crisis has provided invaluable support to NHS staff. I am confident if any Conservative politician had tried to suggest this last year, they would have been lambasted for attempting to undermine NHS staff or for putting the UK on a “slippery slope” towards privatisation.

Since March, I have volunteered with my local hospital – something I feel incredibly fortunate to have been able to do as it enabled me to support the frontline in action.

What struck me at the height of the crisis was how impacted NHS staff were by some sections of the media and those who engaged in baseless NHS political point-scoring. When the news was reporting the country was running out of PPE, despite the fact my local hospital had stock, I could hear the concern in the voices of some staff that they thought they were about to run out imminently.

Like the rest of the country, NHS staff, too, are watching the news day after day. When they hear a constant flow of the absolute worst-case scenarios presented as the norm, it understandably affects their anxiety levels.

Whilst the NHS has been presented with challenges it had never faced before, the unhealthy obsession with scaremongering poses a threat to NHS employees mental health and the morale of the nation.

Our NHS is the most prized possession in the Government’s arsenal, and it has become a proud cultural symbol for Britain. The uncorroborated and alarmist claims by part of the media and fed by some politicians deny honest and nuanced debate about the issues facing the NHS and social care both during Covid and looking long-term.

One of the many reasons I am proud to be a new MP as part of the 2019 intake is because of our Party’s renewed focus on health social care. During Labour’s time running the NHS, use of Public Finance Initiatives (PFI) increased to the point that even The Guardian described its crippling effects on hospital budgets.

It was Hancock who wrote £13.4 billion off hospital debts, much of which had accumulated due to PFI contracts. It was formerly Chancellor Phillip Hammond who ended the use of PFI and PF2 contracts. It was the last Labour government who privatised Hinchingbrooke Hospital, which the Conservatives then took back into public ownership in 2015.

More recently, the opposition has found itself at odds with the CMO and BMA over attempts to change testing policies through an amendment in Parliament. Even during the early history of the NHS, it was Labour who introduced prescription charges along with charges for spectacles and dentistry.

As a member of the Health and Social Care (HSC) select committee, I don’t shy away from being critical myself. I am aware of the need for transformation in many areas. It has been clear to me that the parity of esteem between physical and mental health, for example, needs addressing much more robustly. As does the parity between NHS and social care workers.

The good news is I believe the decision-makers for these areas have heard this call loud and clear from the very top and are focussing on solutions.

The announcement by Hancock mid-August regarding the creation of the NIHP was an important step that sadly once again had to battle against the noise of opposition repeating the old “privatisation” rhetoric.

For anyone who listened carefully, they would have heard this critical line at the end of the speech. The Secretary of State said, “It (NIHP) will work hand in glove with the NHS, and it will use the most modern, cutting-edge digital and data analytics tools at its core.” Such remarks are not about privatisation, but about a new era of agile government supported by highly capable health agencies.

The easing of unnecessarily bureaucratic systems, the harnessing of technological capabilities, the rise of telemedicine and enhancing the powers of frontline staff should now become the new norm for healthcare.

We have also seen a robust partnership with AstraZeneca and others with the vaccine development, the use of private healthcare facilities for public purpose and the building of the Nightingale Hospitals’ at a record pace. The Government will enable the NHS to spend £10 billion over the next four years on private hospitals to tackle waiting lists.

Not one aspect of this has been a drive towards privatisation, but a more collaborative way of working that aims to benefit patients and staff.

I am not arguing that the Government shouldn’t be put under intense scrutiny by the opposition – in fact – I welcome it. We must end this knee-jerk media scaremongering that only puts fear into the most vulnerable and those working on the frontline.

What we need is a visionary approach to healthcare for this century if we want to seek ways improving patient outcomes and being the best possible employer for Health & Social Care staff. 65 per cent of the NHS’s history has been under a Conservative government, and privatisation simply has not happened under our watch.

Tania Mathias: Social care reform should be Johnson’s legacy as much as Brexit

6 Jul

Tania Mathias is an NHS doctor and former MP for Twickenham.

At the weekend Sir Simon Stevens deftly moved away from the problems during the current pandemic – that have led to NHS doctors protesting outside Downing Street, fears about the lack of PPE, and the paucity of testing – by commenting on the much needed reform of social care which had been highlighted well before SARS-CoV-2 had reached its human host.

Many clapped for the NHS at five o’clock on Sunday. Next year, if we have had progress in medical and social care integration, it could be a clap for NHSCARE.

Theresa May’s manifesto in 2017 addressed the need for social care reform, and we have had a Green Paper promised ever since. Now is a perfect rainbow: we need more people opting to work in the social care sector, and many people in retail and hospitality are facing the need to re-train and look for other jobs. If we can ride the wave of respect and current attention on the NHS, we can direct people seeking work to the care sector.

This year is the opportunity to give more status – financially and culturally – to jobs involving person-to-person care. Several Cabinet Ministers have spoken about the challenge of the fourth industrial revolution. High tech jobs are a dominant need in our society yet the often missed need is the “high touch” or empathetic jobs that are needed yet no artificial intelligence can mimic.

People do not need to have a calling or a vocation to be able to look after another human being who is in need of personal care. The new Job Centre mentors need to look to filling care jobs that also have a career structure to help the thousands of people who suddenly find themselves unemployed.

The Cavendish report addressed the need for a better career structure for care workers. Indeed, better training may have saved lives during this first pandemic peak. For example, who saw the images of the fire brigade workers training care workers how to put on PPE and wondered shouldn’t the care worker being the one to teach the fire brigade how to do this?

Care has been an overlooked career but now is a rainbow opportunity to bring a range of people from different life and job experiences into the care sector to fill vacancies. Instead of furlough, the Government could be subsidising the wages for people entering the care sector.

Longer term the Government could be encouraging companies to give their skills to the care sector. The Territorial Army is a template and now we have a chance to move some of the COVID-19 volunteers into a NHSCARE army, or rather NHSCARE family.

Sir Simon Stevens referenced Beveridge’s five evils. And I am told Margaret Thatcher kept a copy of Beveridge’s report in her famous handbag. I don’t care if that latter anecdote is true or not: the point is Thatcher cared deeply about the end to want, disease, ignorance squalor and idleness. A boost in recruitment in the care sector can address several of these issues at once.

Prime Minister Boris Johnson’s term of office was expected to be dominated by Brexit. A greater legacy will be a care sector fit for the next 72 years and integrated with a stronger NHS – the birth of NHSCARE. Thatcher would be proud methinks.