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The gathering storm of the next NHS crisis


There are roughly half a million beds in residential or nursing care homes in the UK.1 Private providers operate almost all of these beds (90%) though the sector isn’t particularly lucrative: the average operator draws a profit of less than £5 per resident per day. Most beds are funded either in full (40%) or in part (10%) by local authorities. The NHS pays for a few (5%).

Central Government funding to local authorities was cut by 25% per person over the period of the last Government, though these cuts were not uniformly distributed across the country. This came on top of smaller reductions in funding over the previous five years. As a result, local authorities had much less to spend on social care. The number of day care places plummetted by 50% over a decade. About 20% fewer people received local authority funded care in their own home. And, partly as a result of this, the number of older people in residential or nursing care homes rose by more than 20%.

Over the next five years, we will see a perfect storm in social care for elderly people. The number of people aged over 75 is predicted to grow from 5.3 million today to 6.1 million in 2020 (a virtually unprecedented rate of increase, almost double what happened over the last five years). Yet Central Government funding to local authorities is to be cut further. Funding is being reduced while demand is predicted to increase more than ever before.

The burden will fall on the NHS, as it is in NHS beds that people often wait for care home places. The absurdity of this is that the average per-night cost of staying in an NHS hospital is three times greater than the average care home cost.


Yet there is another insidious factor imposed by Government which will push this situation from ‘substantial problem’ to ‘perfect storm’.

Most workers in residential and nursing care homes are paid minimum wage. By 2020, this will rise fromt £6.50 to £9.

Few could argue with giving hard-pressed workers a living wage. But given that average care home profits are less than 21p per patient per hour, care homes cannot maintain their current charges while increasing staff wages by £2.50 per hour. Yet they cannot raise their fees because Government cuts mean that local authorities can’t pay.

So what happens when care costs increase and funding decreases? First, care is cut: HC-One, Britain’s third-largest care home provider, is already training carers to take on highly skilled tasks which were previously done by more experienced and expensive nursing staff. But, since the cost of those carers is also increasing rapidly, this is only a stop gap solution. As Southern Cross, previously the UK’s largest care home provider, showed in 2011: care home providers can and will collapse.

As care home companies collapse, the supply of care home beds collapses with them. More elderly people get ‘stuck’ in NHS beds, at much greater cost to the taxpayer, and much greater risk to their own health.

And, to add extra thunderbolts to the storm, the number of NHS beds is decreasing rapidly: by nearly a quarter over the last ten years, with no sign of slowing. In this context, an increase in elderly people needlessly occupying NHS beds due to a lack of social care will cause the NHS to grind to a halt.

The underlying problem here is that the Government fails to understand that protecting NHS funding does not protect NHS services. Health and social care are two arms of the same beast: cutting one leaves the other with more to do. Yet the long-term solution isn’t obvious: there are limits to the burden of tax people are willing to carry to fund health and social care services.

The forecast is for bigger storms ahead.


  1. As with all posts like this, I’m using rough figures to illustrate the broad situation. These are thumbnail figures, not accurate-to-the-penny accountant’s figures. 

This 2,303rd post was filed under: Health, News and Comment, Politics, , , .

Netflix might tell us why the election polls were wrong

Netflix headquarters in Los Gatos, California, Thursday, July 10, 2014 for Alibaba.  (Paul Sakuma Photography) www.paulsakuma.com

It’s said that so-called ‘shy Tories’ swung the General Election: those people who are unwilling to admit to pollsters that they vote Tory for fear of a negative response, but who put their cross next to a Conservative candidate’s name in the privacy of the polling booth.

‘Shy Tories’ is basically a shorthand for a particular form of social desirability bias. When asked questions by pollsters, we may be unwilling to admit views that we think might upset pollsters. After all, most people like to please people.

Online polls, so the theory goes, should be less susceptible to social desirability bias because they remove the imposing pollster from the equation. Peter Kellner, President of YouGov suggests:

One of virtues of online research is, or should be, that it allows respondents to submit their views with complete anonymity, as there is no stranger watching over them or listening to their answer.

Or should be. An important caveat given that YouGov, online pollsters, were as wrong in their General Election predictions as telephone pollsters.


So perhaps social desirability bias exists online just as much as elsewhere. Perhaps. And there’s an intriguing piece of evidence from, of all places, Netflix, which described this week putting much greater emphasis on recommending shows based on what people actually watch, as opposed to how they rate individual shows. Todd Yellin, Netflix‘s VP of Product Innovation reports:

Most of our personalization right now is based on what they actually watch, and not what they say they like, because you can give five stars to An Inconvenient Truth because it’s changing the world, but you might watch Paul Blart: Mall Cop 2, three times in a few years … so what you actually want and what actually say that you want are very different.

Is rating something highly because it’s changing the world rather than because you actually enjoyed it a form of social desirability bias? I reckon it probably is. I reckon it’s an attempt to make ourselves feel more educated and ‘worthy’.

And if we fake our Netflix ratings, conning only ourselves, why wouldn’t we equally fake our responses to online polls?

This 2,302nd post was filed under: Election 2015, News and Comment, Politics, , , , .

James is wrong about giving 16- and 17-year-olds the vote

My friend James O’Malley argues on his blog that 16- and 17-year-olds should be given the vote as it will help to tackle the seemingly undue attention given to old people by political parties:

By increasing the potential pool of voters at the bottom, it affects the potential electoral mathematics that the parties have to do to maximise their votes. If there are more young people who can vote, it tips the scales back towards the young. Pensioners might be reliable voters, but if there were an extra 1.6 million (ish) young people on the electoral register might be a greater motive for refocusing policies and priorities.

I’m undecided on whether 16- and 17-year olds should be allowed to vote―I see good arguments on both sides―but I think that James’s specific argument is wrong for reasons mathematic and democratic.


First, the maths. For the purposes of these back-of-the-envelope calculations, I’m using ONS projections for England (as that’s what I have at hand), defining the “youth” vote as 29-and-under,1 and defining the “grey” vote as sixty-and-over.

Currently, the “youth” vote accounts for roughly 20% of eligible voters, versus roughly 29% for the “grey vote”. Giving the vote to 16- and 17-year olds would move these percentages to about 22% and 29%: that is to say, it wouldn’t make much difference. And the difference is lessened further by the fact that most people agree that the “youth” vote is less likely to turn out than the “grey” vote.

But, of course, the real imbalance in the “youth” versus “grey” votes isn’t in 2015. The population is ageing: the scale of the imbalance today is nothing to what the scale of the imbalance will be in the future.

If we fast-forward a couple of decades to the 2035 election, ONS projections suggest that the “youth” vote (as currently defined) would make up roughly 18% of the electorate, versus 37% of the electorate being “grey” voters. Giving 16- and 17- year-olds the vote rebalances this a titchy bit (to 20% and 36% respectively), but this difference is really so little as to be meaningless―the imbalance remains far greater than it is today.


My second problem with James’s argument is democratic. He reckons that the makeup of the electorate needs to be changed to better ‘balance’ it in age terms, because generational disputes cause problems in our country. As an example:

The old, who own property want the value of their homes to continue to increase, whilst it would be better for the young people who Ed Miliband calls “generation rent” if property prices were to fall, so that buying a house can become even a remote possibility.

But, surely, to suggest that’s a problem is profoundly undemocratic! We have decided that the best way to run our nation is by the majority electing representatives who they think will best serve their interests. The majority of the population is ageing. We shouldn’t go around thinking of ways to “fix” the result to better reflect youth interests because the youth is in the minority.

If we stick with our current form of representational democracy, then, for the foreseeable future, our politics will continue to be determined by the “grey” vote as it is the “grey” vote which makes up the largest part of the electorate. The different electoral turnouts between the generations certainly exacerbate the problem, but they are not the source of it.


Having said all of that, there is a problem here. Actually, it probably is unreasonable for the electorate to become so imbalanced: not generationally imbalanced, but gratuitously imbalanced between net financial contributors to the state and net financial users of state services. It’s hard to see how a state can function when politicians essentially only have to appeal to those who use the state’s services (especially the elderly), and have to appeal less to those who (by and large) pay for it (largely the working aged). It becomes perfectly logical for politicians to whack up tax rates or borrow with little regard for the future.

Of course, this probably won’t actually happen. It’s more likely that the “grey” vote will be effectively capped at a certain size as people work longer, as neither the state nor individuals can afford to pay for pensions which increasingly approach or exceed the length of an individual’s working life. And, of course, outrageous levels of tax and spend would provide a good incentive to improve low turnout in the younger section of the electorate, which would provide a degree of rebalance in and of itself.


On the other hand… things could get worse more quickly. We’re seeing national and international narrative opinion increasingly extending the length of childhood. We’ve already seen in the UK a major shift in legislation pushing the end of childhood (in terms of, for example, school leaving and consumption of cigarettes) from 16 to 18. There is increasing scientific evidence that key elements of development, particularly emotional development, continue until the early 20s. UNESCO considers our period of “youth” to continue until 25. The African Youth Charter considers it to continue until 35. In this context, it’s not inconceivable that a future government might choose to increase the voting age, not decrease it.

To summarise: give 16- and 17-year-olds the vote if you want. But do it for good reasons, not because you want to “fix” the outcome of elections in a way that will matter little and matter for a short time. And go and read James’s post, too.

  1. Woe is me, having just exited my own definition of “young”. 

As a bit of an experiment, you can access an audio version of this post here.

The images in this post are all from Flickr, and are used under their Creative Commons licence. In order of appearance, they were uploaded by Eric Hossinger, AdamKR, The Fixed Factor, and James West.

This 2,301st post was filed under: Politics, .

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