Tim Kelsey
Brian Jarman, emeritus professor of general practice at Imperial College, is a kindly looking man. He is famous in medicine for designing the statistical model that was used to pay GPs (the Jarman Index); leading the campaign to keep Barts Hospital open; and, 15 years ago and perhaps most notably, devising a way of predicting how likely patients are to die in hospital. That analysis revealed that death rates in England, even when controlled for variables like a patient’s age or class, differed by up to 76 per cent.
Death rates are not universally accepted as the best way to measure a good hospital. But tragic events keep bringing the issue back onto the agenda. In 2001, the Kennedy inquiry into children’s heart surgery at the Bristol Royal Infirmary found that up to 35 babies may have died unnecessarily during the early 1990s. The inquiry called for more surveillance of hospital performance. This year just such an analysis uncovered another scandal at Stafford General Hospital, where receptionists rather than nurses were deciding which patients needed urgent treatment when they came to A&E. The healthcare regulator found that 400 lives may have been lost; deaths which smarter analysis of data might have prevented.
Yet the spread of such analysis in our health service has been painfully slow. Because Jarman’s original methodology used data taken from confidential patient records, the secretary of state for health had to give formal consent for its publication. This was refused for years. Politicians of both parties were nervous: how would the public respond to evidence that the NHS is a dangerous postcode lottery? Only in 2001 did health secretary Alan Milburn take a different view and authorise the publication of the hospital standardised mortality ratio (HSMR) in the Good Hospital Guide. (My company, Dr Foster, publishes this guide and provides other data about the quality of local health services.) Since then, better use of data has slowly begun to change the ways the NHS is run. Walsall hospital, for instance, had the highest death rate in 2001, recording 1,080 deaths when it should have had only around 830. By 2004 it had improved its performance dramatically through a number of innovations in clinical practice and probably saves more than 275 lives a year as a result.
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prospect
You can also read John Lloyd’s accompanying feature on the future of public service broadcasting for free on our website here
Prospect (P): Let’s start with the license fee and its long term viability. Some critics say it can’t last.
Mark Thompson (MT): The big question here is whether the British public want to pool their resources to pay something valuable that they can all use. In the 1980s, people like Professor Alan Peacock argued that the BBC’s reach and the value of what its did would be eroded by the number of choices offered by digital television, and that this would undermine the idea of every household paying a compulsory charge. This has not proved to be the case: the BBC’s reach and perceived indispensability to virtually every household in the UK still feels very secure. You may argue that a television license fee may no longer be the right fiscal treatment—but it seems to me that, if the public and political support for a shared investment exists, fiscal means can be found to pay for it.
P: The other fiscal means would be through the normal tax revenue…
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David Willetts
View the details of the Prospect/YouGov poll on Margaret Thatcher’s legacy here; and discuss this article at First Drafts, Prospect’s blog
The election of the Conservative government 30 years ago on 3rd May 1979 is one of the key dates in Britain’s modern political history. That anniversary is not being marked by careful analyses of monetarism or privatisation but a focus on the character of Margaret Thatcher, with old animosities and caricatures out on display again. It is still very difficult to get a measured judgement of the 1980s without it all turning on what you think of Her.
There are many reasons for challenging this focus on her personality. For a start it fails to give adequate weight to the formidable intellects and political operators around her. Even in opposition in the late 1970s the process whereby Geoffrey Howe and Keith Joseph argued their way through key documents such as “The Right Approach to the Economy” turned out to be an effective way of preparing for government. A recent BBC play presented her as driven by the need to humiliate the men around her. But this is to misunderstand her argumentativeness—she believed in truth through conflict. She challenged and tested people and their arguments but, at least until her final period in power, there were always ways of arguing back which the key people around her mastered and which she respected. I know because I saw it. I was a middle period Thatcherite. I had been a junior treasury official during the battles of the early years when we just had to get a grip on public spending and stabilise the finances. Then for three years in the mid-1980s I was a member of her policy unit. The challenge, one of the hardest for any government, was to develop new ideas after years in office.
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James Crabtree
Discuss this article at First Drafts, Prospect ’s blog
Politicians like talking about parent power. Tony Blair promoted his 2006 Education Act with boasts of a new era of parental choice. Today, David Cameron is in on the act—promising a Tory parental revolution, and a new “great Education Act” in his first 100 days.
For Emma Jones, though, such high rhetoric has a rather empty sound. About five years ago she began to worry about where her son and daughter would go to secondary school. A theatre director by profession, she and her young family lived in a small enclave of London’s borough of Camden, just south of the busy Euston Road. Although both children went to one of the five local primary schools, she knew there was no acceptable local secondary. The nearest were academically weak, to find an alternative would mean travelling many miles across the city.
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Richard Reeves
When Margaret Thatcher sat down with her first cabinet in No 10, one of the agenda items was a plan to free local authorities from Whitehall control. It didn’t quite work out. Thatcher herself recalled that she was soon “forced down the path of still tougher, financial controls, as the inability or refusal of local councils to run services efficiently became increasingly apparent.” Tony Travers at the LSE characterises her reign as an “11-year-long war against local government.”
Today a truce has been declared. David Cameron describes himself as a “confirmed localist.” Thoughtful Tories, like Oliver Letwin, look back to an older, Burkean tradition concerned with the “little platoons” of local communities. Last month the Conservatives launched a green paper on the issue, which Cameron advisers think contains some of the most radical ideas they will bring into government. They may find more allies in future, given that many of the expected new Tory MPs will have earned their stripes in town halls. Some of his opponents, too, will warm to these ideas. In 2006, David Miliband argued that Labour politics needed what he called a “double devolution,” by which he meant giving power to local authorities, who would in turn give it to individuals. “Devolution is a deal,” he declared.
Amen to that, say the new Tories. But they want to go farther. The Conservatives say that they will allow more elected mayors, but only if a majority vote for them in referendums. Local taxpayers, they say, will be able to veto large council tax rises, again by referendum. But the most important Conservative proposal—one largely overlooked—is to grant councils a “general power of competence.” In future they will not need a specific mandate to act, but can undertake any lawful activity without a permission slip from Whitehall. On paper, it indicates a profound change in the relationship between central and local government.
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Richard Reeves
Never let a good crisis go to waste,” insists Rahm Emmanuel, the hardbitten chief of staff to Barack Obama. Certainly, economic disaster and political disequilibrium create the space for new thinking. They make and break reputations too.
Gordon Brown is trying to bring the British economy down gently. A little like the passengers of Flight 1549 approaching the waters of the Hudson, voters are anxiously wondering if the captain can land safely. In private, even senior government figures now admit that Britain’s economy may shrink by 4 per cent in 2009—a downturn twice as deep as official projections. Latest polls, at least, suggest that faith in the pilot is waning.
As a result Labour circles are full, once again, of post-Brown political chatter. There will be no challenge before the election, of course. But the contours of the debate that will engage Labour in opposition are already becoming visible. It’s a dividing line that fractures the other parties too. On the one side stand those for whom the economic crisis demonstrates the need for a more muscular state; on the other, a diverse group who want to use the state to give more power to individuals.
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David Walker
What does the financial crash mean for the growing use of the private sector in the delivery of public services? One might assume after recent events that the public sector is looking rather more solid and reliable, and the market rather riskier and more volatile. Indeed, that seems to be the implication behind Peter Mandelson’s apparent conversion to the view that the post office network should be treasured rather than closed down.
Yet the Sunday Times is tipping shares in Serco, the public sector outsourcing group that, among other things, drives prisoners to court. Its half-year results saw a 21 per cent rise in profits, driven by a new £266m contract with Glasgow city council. The markets seem to think that Serco—which operates the Docklands Light Railway in London—is “infrastructure” of the sort that may gain from Alistair Darling’s rediscovery of the Keynesian virtues. Also, with public spending under pressure after the banking bailout, there’s a view that councils and Whitehall departments may have to seek savings by putting more services out to tender. Bad times for Britain, it seems, could be good for Serco, Capita, Tata, Liberata and all the other outsourcers.
But the share tipsters may have got this wrong. A big rethink is underway at the public-private nexus, less because of a change of attitude in government than because of a less attractive risk:reward ratio for the outsourcers themselves. The plan of James Purnell, the work and pensions secretary, to contract out welfare-to-work services now looks in jeopardy. In America and Australia, the innovative answer has been big contracts for private companies but payment only for success: that is, when ex-claimants are placed in jobs for six months or more. In a tight labour market, profits from such schemes are assured. Now, however, the market’s appetite for risk is much diminished and the latest negotiations show bidders demanding more: more than it costs the government’s Jobcentre Plus to get people into work.
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Andrew Haldenby
Should we all be buying shares in Serco, the public sector out sourcing giant? David Walker’s recent article (”Out with the out sourcers?” Prospect, December 2008) is right that recent moves towards greater outsourcing in the public sector are currently under pressure. But what will actually happen in the coming recession remains an open question. The recent pre-budget report reveals the full, sorry state of the government’s finances, and analysis of the document clearly shows that whichever party is in power is going to have to find savings of £37bn on the Treasury’s own figures. Against such a background, the downturn may well provide an impetus for more outsourcing, not less. And this would be no bad thing.
Let us start with the facts. Walker is correct to note that Blair-era promises of public sector outsourcing are currently going up in smoke. Only as recently as 2004, John Reid was speaking of 15 per cent of NHS operations being carried out by private sector companies. In fact (while the figures are complicated) it is now no more than two per cent and probably falling. Brave promises on initiatives like independent sector treatment centers were quietly cut back under Gordon Brown.
At a recent HealthInvestor round table, Mark Adams of VirginHealthcare said that his local health commissioner, the public body which buys healthcare in local areas, had promised him that £700m of services would become subject to open competition in due course. It finally tendered a £50,000 contract for vasectomies. As Mark said: “You go to your board of directors and say, ‘I know we’ve heard all this before, but this is the scale of the new opportunity’ … when you tell them it’s turned into a £50,000 vasectomy contract you don’t look too clever.” This cut in previously bold Blairite plans for the use of the private sector is rather different from the of snip to the one that David mentioned, namely the value of Serco shares.
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Ben Page
Imagine a country where virtually everyone describes themselves as satisfied with their lives—only 13 per cent say they are unhappy. Where 95 per cent say they are close to their families and 76 per cent are confident about their personal futures. A country that is markedly better off than a decade before, with 600,000 fewer people in poverty and 1m fewer on out-of-work benefits. A country with universal free healthcare and the highest recorded level of satisfaction with that service, with waiting times the lowest for 40 years. A country which most people think is a good place to raise children and where most children are felt to have far better prospects than their parents had before them. But in that same country, when asked whether life in general is getting better or worse, 71 per cent of people say life is getting worse, up from 60 per cent in 2007 and only 40 per cent in 1998.
This country is, of course, Britain. Last September, David Cameron, the man most likely to be its next prime minister, said: “The biggest challenge facing Britain today is mending our broken society… Four in every five youngsters receiving custodial sentences have no qualifications. More than two thirds of prisoners are illiterate. And nearly one third of those excluded from school have been involved with substance abuse… 43 per cent of 11 year olds cannot read, write and add up properly. Last month, more than 20,000 pupils left school without a GCSE. And right now, more than a million young people are not in education, work or training.”
The Conservatives have made much of this “broken Britain” narrative. But what does it actually amount to? Strip away the rhetoric, and you find three basic claims: crime and antisocial behaviour are rampant; the institution of the family is in dangerous decline; and there is a growing underclass of poorly educated, “feral” young people.
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Alison Wolf
On 1st March 2007, in a nondescript Birmingham committee room, a panel of consultant surgeons decided to break their employment contracts. In doing so, they guaranteed the front-page storm that government officials were hoping to avoid. Two weeks later, thousands of junior doctors noisily demonstrated in London demanding jobs and training. Patricia Hewitt, secretary of state for health, apologised to the doctors, was “supported” by her party—and then duly dumped that summer. So began one of the most profound and emblematic crises the NHS has suffered in its 60-year history.
What did the Birmingham surgeons do? They simply refused to continue interviewing applicants who had been shortlisted for junior doctor appointments in their area. The system for shortlisting and appointing was, in their view, fundamentally unfair. The winter of 2006-07 had seen the introduction of a new centralised, website-based approach to the appointment of junior doctors to posts and to their training. All over the country, there was growing panic and anger among doctors at the results—both the nature of the new system and the enormous gulf between the 32,000 doctors applying and the 15,000 or so training places available.
A year later, another round of appointments is in full swing, and all seems quiet. So was last year just another one-off Terminal 5-style fiasco, in which new systems crashed and inexperienced staff made mistakes before things settled down? Sadly not. What happened was the result of a gathering crisis in medical education, born of chaotic policies for recruitment and training and made worse by a naive faith in central planning and the vagaries of immigration policy. Put simply, far too many junior doctors—British and foreign—are entering the system for the training opportunities and senior jobs on offer, and this problem will remain with us for years to come.
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