In sixteenth-century Venice, some long-forgotten enterprising businessman came up with a new way to make money. Customers would buy tickets for a fixed price which would be put into an urn. Tickets representing things that people wanted to buy—“precios”, or “prizes”, such as silk, beads, cats, and horses—were put into a second urn, along with some simply marked “pacientia”, or “patience”.

After a while, sales of tickets would cease, and the trader would simultaneously draw tickets from each urn: those whose ticket came out at the same time as one bearing the name of a prize would win it; those whose ticket came out at the same time as one bearing “patience” would win nothing.

This became known as “lotto”, and before long, everyone was obsessed, as captured in the famous diaries of Marin Sanudo:

At present, in this Rialto district, nothing is done except put money on the lottery. First anyone who wished to adventure had to give 20 soldi, then it grew to 3 lire, then to a ducat. And the prizes were carpets and other things; now there are money prizes, 200 ducats, and a piece of cloth of gold has been offered.

As this business grew and grew, the draws got bigger and bigger, sometimes lasting days at a time and drawing huge crowds. Before long, people worked out how to piggyback on the lotto market to make a secondary profit: selling the rights to tickets at inflated prices once the draw had started, with the twin advantages of: the in-play ticket having a higher change of winning because of the elimination of smaller prices (essentially, sixteenth-century Deal or No Deal); and capitalising on the fact that people didn’t have the time to stand around to wait for the culmination of a multi-day draw. This market in second-hand tickets become known as “bagarinaggio”.

This game had sticking power, and—despite an early decline at the hands of over-zealous Italian tax reforms—is the foundation on which everything from the National Lottery to charity raffles to Christmas tombolas is built.

Perhaps the closest modern analogue to sixteenth-century Venice’s favourite game is bingo. Unlike most other descendants of the idea, bingo retains the aspect of bringing large crowds together at one time in one place to apparently compete in an activity whose winner is randomly determined.

Before we go on… a personal confession. I don’t enjoy bingo: I find it interminably dull. We used to play bingo at home with relatives at Christmas when I was little, and I always wanted to be the bingo caller because being the player was so very boring. It just does nothing for me at all.

After a period being played underground—especially in the First World War—bingo was finally legalised in Britain in 1960. At once, the craze swept the nation. By 1963, something like a third of the adult population—14 million people—were members of bingo clubs. As high street picture houses and dance halls became unprofitable with the rise of television, they were often converted into bingo halls.

Perhaps because gambling was still a little unseemly, or perhaps to extend their reach, bingo halls often called themselves something else entirely: two large operators, Top Rank and Granada plumped for “social clubs”. It’s hard not to notice the similarity to coffee shops today: these frequently try and sell themselves as community hubs or venues for groups to meet, rather than merely shops that sell hot beverages. Perhaps it’s a necessary part of winning “heart and minds” to facilitate a rapid expansion.

Over the next two decades, bingo halls went from strength to strength. By the 1980s, national bingo games were being launched which networked clubs across the country together, and the first purpose-built bingo halls were appearing on the scene.

But in the 1990s, things changed. Bingo started to decline. This seems to be most commonly attributed to the National Lottery, but—to my mind, at least—this seems an unlikely association. It strikes me that there is a considerable difference between attending a bingo club with friends and the solitary activity of buying a lottery ticket at the corner shop. The bigger problem may have been that the average age of a bingo club member in 1990 was 62, and tastes had simply moved on.

Bingo hall after bingo hall closed—a fifth of all halls closed between 1995 and 2000. The decline continued into the new century, arguably hastened by the introduction of the smoking ban in 2007: industry experts estimate that some 50% of players previously smoked while playing, and many of them left when this was banned.

Also in 2007, in response to claims that the National Lottery’s huge jackpots had harmed the bingo industry, the Gambling Act allowed clubs to introduce games with rollover prizes for the first time. This led to much bigger jackpots: just months after the new rules were introduced, there was widespread media coverage of a £1.1million win.

Despite this—and perhaps giving the lie to the idea that National Lottery jackpots were behind the decline in the first place—the bingo sector continued to shrink, serving just 3 million customers in 2011. By June 2012, just 468 bingo clubs remained—and 16% of those closed by June 2013.

In March 2014, Chancellor George Osbourne cut the tax on bingo halls from 20% to 10% “to protect jobs and protect communities”—though given the moribund state of the industry, it’s hard to imagine there was much left to protect. It has had some effect: chains new clubs are opening, albeit in the single-figures after many years of double-digit decline. I suspect that club number have continued to fall on an industry-wide basis, but can’t find the figures to confirm this. Commentators claim that chains opening new venues is evidence of revitalisation of the bingo industry; I’m afraid I simply can’t see it. I can’t foresee bingo halls being more than a historical curiosity in a decade’s time. Perhaps I’m wrong.

But, of course, there’s a whole other side to this story. Online bingo has grown exponentially over the last decade: there were 20 UK bingo sites in 2004, while there are 350 today. The lack of venue overheads has transformed the cost structure of the game: online games cost as little as a penny, and rarely more than 10p. And the industry’s expansion has heralded new operators, perhaps better equipped to compete in the digital world that bingo hall operators of old.

Many of the market leaders, such as Foxy Bingo, Costa Bingo and Cheeky Bingo are entirely new operators. It has been said that The Sun makes more money from its online bingo operation that it does from selling newspapers.

Allow me another personal confession: I don’t understand the appeal of online bingo. When given a free trial of a couple of sites, I could not have been more bored. At least in physical bingo, one does have to keep up with marking one’s tickets. Not so in most versions of online bingo, where either tickets are marked for you, or you are declared to have won whether you keep up or not. All of the sites also had chat rooms, but these were qualitatively no different to those that can be found anywhere online: they certainly didn’t strike me as a compelling reason to log on to the sites. The experience isn’t one I’d recommend.

The online bingo market seems like it is still nascent. The explosive growth of advertising for bingo sites is necessary as indications are that brand recognition and loyalty seems fairly poor: when Google changed its search rankings in 2013, it transformed the market. 888, which used to be everywhere, was one of the big losers of this change.

It’s curious that some bingo sites—much like early bingo halls—are starting to position themselves more as online social venues that gambling sites. It’s hard to tell whether this is a reflection of genuine demand, or a fig leaf to cover the desire to gamble as it seems to have been in the 1960s.

With the lack of interaction necessary in online bingo games, I wonder whether they are really “bingo” in the traditional sense at all. Perhaps sixteenth century Italian lotto has taken another evolutionary step; or perhaps online bingo—bingo without the time and concentration commitment—is today’s “bagarinaggio“.

In a case of history repeating itself yet again, politicians seem to be starting to consider online gambling as a possible source of tax income: just like the Italians centuries ago and the bingo halls of the 1960s, the market might be harmed by burdensome tax rates.

Really, I’ve no idea what the future holds. But one thing is certain: I’ll enjoy standing by and watching more than I’d enjoy a game of bingo.

You can read far more on the history of bingo in Britain in this fascinating report written by my friend Graham Soult for Two Little Fleas.

Answer me this: what happened to waiting times in A&Es in England last week? To help you answer, here are some tweets published by reputable news organisations today:

A&E waiting times in England improve to their best level since November, figures show http://t.co/N2ib5ttFyO pic.twitter.com/YVALTkJ9qW

— BBC News (UK) (@BBCNews) January 23, 2015

A&E waiting times in England improve http://t.co/mQtiuk12yc

— The Guardian (@guardian) January 23, 2015

NHS England pays tribute to staff after figures show slight reduction in A&E waiting times http://t.co/PNOq2Yyv9Y pic.twitter.com/mvQfNX3eHS

— ITV News (@itvnews) January 23, 2015

A&E waiting times improve but fail to hit target http://t.co/cC7NO055aB

— PoliticsHome (@politicshome) January 23, 2015

A&E crisis: Waiting times improve for second week running http://t.co/tNTEYstIx6 pic.twitter.com/jWk9FKELmH

— Telegraph News (@TelegraphNews) January 23, 2015

You would be forgiven for thinking that waiting times had reduced. You would be… possibly right, possibly wrong. The correct answer is that we don’t know. Performance against the weekly A&E waiting time targets—which is what all of the above are actually reporting—tells us nothing about the waiting time in A&E.

As an aside, before we get into this properly, I should clarify that “waiting time” doesn’t mean what most people think it means. The “waiting time” referred to in these statistics is the total time a patient spends in A&E, from the moment they walk in the door, to the moment they walk out again (whether that is to go home, to go to a ward, to go to the pub, or wherever). That’s not what we think of as “waiting” in common parlance: while you’re with the doctor, you are—in statistical terms—still “waiting”.

The NHS doesn’t report on waiting times, only on the proportion of patients seen in less than four hours. When the reporters wrongly say that A&E waiting times have improved, what they actually mean is that a greater proportion of people entering A&E are leaving again in less than four hours. This tells nothing about the amount of time people wait on average.

Imagine an A&E department that sees only five patients: A and B have minor injuries, and are seen and treated within 30 minutes. C and D need a more complex set of investigations, so end up being in the A&E department for 3 hours. E needs a very full assessment and ultimately admission; as a result, E ends up being in the department for a total of 5 hours before a bed can be found. The average time these patients spend in A&E is 2 hours and 24 minutes; 80% of them were discharged in 4 hours.

Now let’s say that someone puts a laser-focus on that 80% and says it’s unacceptable: whatever the cost, it must be brought down. So the department tells the nurse that used to do the “see and treat” job (which served patients A and B so well) that she must help with only the most complex patients, because they are breaching the target.

The same five people with the same five injuries now come into the revamped A&E. A and B have minor injuries, but now must wait alongside everyone else. They hang around for 3 hours. C and D need complex investigations, but these are slower to start because of people with minor injuries clogging up the queue. They are discharged after 4 hours. The new complex patient team deals with patient E slightly faster, getting her up to the ward with seconds to spare before the four-hour deadline.

100% of patients were seen within 4 hours. The hospital’s management is overjoyed! The BBC tweets that A&E waiting times have decreased: 100% of patients are seen within four hours instead of 80%. Politicians become a little self-congratulatory.

Yet… what has actually happened? The average waiting time has increased from 2 hours and 24 minutes to 3 hours and 36 minutes. 80% of patients are waiting longer than they did before.

And that is why—whatever the news tells you—we have no idea what happened to A&E waiting times last week. The average time could have doubled; it could have halved; it could have stayed precisely the same. We simply do not know.

Today, I finished reading a rather unusual book. Marie Kondo’s The life-changing magic of tidying is a book for which I wouldn’t have had even a passing consideration had it not been for a recommendation from Tim Harford in the Financial Times. Tim—an economist—reckoned that a book on tidying had—in his words—”rocked his world”. This I had to read.

Kondo’s book rocked my world, too.

Kondo is a professional tidying coach. Who knew that such a thing existed? Her advice, delivered in a way that can only be described as heartfelt and beguiling, is to bin most of what you own, and form an intimate relationship with what is left. And when I say intimate relationship… this is a lady who believes most strongly in talking to your possessions at length, caressing the spines of your books, and treating every inanimate object in your home as if it is your friend.

Her horror at some of her clients seemingly innocuous actions—balling socks, hanging shirts, keeping shower gel in the shower—is absurd, yet delivered with such passion that it becomes entirely endearing.

I so badly wanted to share so many passages from this short book that it might have come close to plagiarism. But because I really, really want you to buy the book and experience the beguiling madness for yourself, I’ve chosen a single passage from the start of a chapter to give you a flavour of the advice within.

 This is the routine I follow every day when I return from work. First, I unlock the door and announce to my house, ‘I’m home!’ Picking up the pair of shoes I wore yesterday and left out in the hall, I say, ‘Thank you very much for your hard work,’ and put them away in the shoe cupboard. Then I take off the shoes I wore today and place them neatly in the hall. Heading to the kitchen, I put the kettle on and go to my bedroom. There I lay my handbag gently on the soft sheepskin rug and take off my outdoor clothes. I put my jacket and dress on a hangar, say ‘Good job!’ and hang them temporarily from the wardrobe doorknob. I put my tights in a laundry basket that fits into the bottom right corner of my cupboard, open a drawer, select the clothes I feel like wearing indoors and get dressed. I greet the waist-high potted plant by the window and stroke its leaves.

My next task is to empty the contents of my handbag onto the rug and put each item away in its place. First I remove all the receipts. Then I put my purse in its designated box in a drawer under my bed with a word of gratitude. I place my train pass and my business card holder beside it. I put my wristwatch in a pink antique case in the same drawer and place my necklace and earrings on the accessory tray beside it. Before closing the drawer, I say, ‘Thanks for all you did for me today.’

Despite—or, perhaps, because of—the madness, it seems to me that there is actually some really sound advice in this book. And Kondo’s enthusiasm for tidying is contagious. I couldn’t help but do a bit of tidying while reading.

So wonderful craziness with a dash of sense and a heap of motivation. What’s not to love? Trust me, Marie Kondo’s The life-changing magic of tidying is a book you will really enjoy—even if it would usually be the last thing on your reading list.

In the game of poker that is the planning process for General Election TV debates, Cameron—the player with most to lose—is currently playing best. The broadcasters have played worst, totally fumbling their hand.

Cameron patently has the most to lose from taking part in the debates. Unlike Miliband and Clegg, he’s not all that unpopular as a leader. He has little to gain and much to lose from sharing a platform with Farage, and further legitimising UKIP’s candidacy.

Cameron’s demand for inclusion of the Green Party will not be met by the broadcasters. If it were, it would look like the participants had been chosen on Cameron’s recommendation alone—hardly a fair and impartial source—opening them to justifiable legal challenge from the other parties who want to take part.

So Cameron is faced with two possible outcomes: the broadcasters do not go ahead, in which case he comfortably sidesteps the problem; or—more likely in my view—the broadcasters go ahead and “empty chair” him.

In the latter case, all options remain open to Cameron. Changing his mind, if that’s the way the wind is blowing, is a one-day story at most. He could even duck the first debate, with Farage, on the grounds that he objects to UKIP’s inclusion without the Greens, take or leave the second (3-way) debate for much the same reason, and still face down Miliband in his preferred (and accepted) one-on-one format.

The debate including Farage will doubtless be a fiery occasion which will probably do damage on all fronts—but it’s likely to do more damage to those present than to an absent Cameron. Speeches criticising an absent leader don’t make for nearly such good TV as people yelling at each other. Clegg and Miliband’s commitments to “anyone, anytime” debates means that they can’t duck Farage; it might make sense for Cameron to let them demolish each other one-on-one in the second debate, too.

Cameron’s other advantage, which Miliband seems insistent on handing to him gift-wrapped, is that opponents are now calling for Cameron to debate in airtime they could be using to build a message or attack Cameron’s record. The media’s own obsession with the debates will likely trap them in this neutralised position until there is movement—which, clearly, Cameron will prefer to leave until the last moment. Cameron calculates—I guess accurately—that his apparent prevarication over taking part in TV debates damages him less than full-frontal attacks from his opponents.

The broadcasters bungled this process by announcing a plan rather than debates. The announcement of a plan implied room for negotiation and manoeuvre. Had they had the common sense to announce the invitees, the format, and the dates, making them fixed events to which leaders were invited, the landscape would now look very different—and I’d wager that all four leaders would be signed up.

The spanner in Cameron’s works could come from the “digital debate” proposed by The Guardian, The Telegraph and YouTube, and confirmed last week to include Cameron’s five preferred participants. Yet, despite being proposed a consortium which buys ink by the barrel, nobody seems to have noticed. If the two papers were to announce a date and invitation list on their front pages, along with assurance that they would “empty chair” those who didn’t turn up, all of those invited might find it difficult to graciously decline… and even more so if they could get a broadcaster to commit to covering (but, to ease the legal challenge, not producing) the event.

Unless the digital debate consortium make a move, it seems unlikely that anything will move in this story for a few weeks at least… but it will be fascinating to see how it plays out.

Among my friends, not having an opinion about the Serial podcast is roughly as socially acceptable as not having an opinion on the Cereal Killer cafe. And as someone who listens to a lot of podcasts (most of them actually of radio shows), I feel particularly entitled to have a view.

For those who have been offline over the last few months, Serial was a weekly podcast with a new episode released each week. It was presented and produced by experienced American radio journalist Sarah Koenig. The podcast followed Koenig’s investigation into the 1999 murder of schoolgirl Hae Min Lee, for which her ex-boyfriend, Adnan Syed, had been convicted and imprisoned.

General life and busyness mean that I didn’t quite manage to keep up with the weekly pace of Sarah Koenig and Co’s Serial. A couple of week ago, though, I finally finished the first season; here follow a few jotted thoughts.

It was very addictive…

Serial displaced everything else on my podcast playlist. I listened to episode after episode, and couldn’t get enough. I thoroughly enjoyed it, and look forward with keen anticipation to the second season.

…but not as innovative as many people suggested.

Blog post after newspaper column after magazine review have suggested that Serial‘s format of a single story told over several weeks is novel, yet Radio 4 has used this structure for decades on hundreds (probably thousands) of dramas, and tens (probably hundreds) of documentary series. The combination of a sort of gonzo journalism and drama was, I concede, a little unusual—but not novel.

Sarah Koenig was the perfect host…

I’ve never listened to anything Koenig has done before. I don’t know if she’s a regular on This American Life because (heresy ahead) I don’t listen to that show. But for this, she was perfect. She has a brilliant radio voice and great way of writing text that pulls in the listener. This listener can’t praise her presentation highly enough.

…but the overall tone was odd.

Jonathan Rothwell wrote a few weeks ago about the weirdness of the show’s slightly jaunty ‘whodunnit’ tone and the way in which this jars with the reality of what is being described. This is a real life brutal murder case; the very existence of the journalist’s investigation implies a reasonable suspicion of a miscarriage of justice, with all the additional harm that carries; yet the story is often treated rather lightly. I found the cognitive dissonance of content and tone unsettling.

The production was fantastic…

The handoffs between Koenig’s presentation and clips of interviews and archive material were seamless. I think this owes much to the writing and the presentation, but also the production and compilation of clips that demonstrated each point was impressive. This is something a lot of Radio 4 productions do really badly, so it’s a joy to hear it done well.

…except for the use of music.

Music is powerful, and especially so in radio drama where the only stimulus is auditory. If you add in music underneath a witness’s recorded testimony, it will change my perception of that testimony. If you are trying to make a balanced review of a case to allow me to reach my own conclusions, then your music is likely to be prejudicial. If you are trying to make drama and argue for one side or another, you probably shouldn’t be playing with people’s lives through a podcast.

I worried about the narration overstating facts…

There were a few episodes in which the characterisations of events in the narration extended beyond the described facts of the case. It is difficult to describe exactly what I mean without giving an example – apologies if this counts as a spoiler.

In episode six, there is a lot of discussion of the ‘neighour-boy’. He is reported as having once said that he had been shown the body, but he did not testify at the trial. This is repeatedly characterised Koenig as the ‘neighbour-boy’ being a witness to the murder. This is evidently false: seeing a body is not equivalent to seeing a murder.

There are a few similar incidents through the series, and I can’t quite decide whether they are mere slips of the tongue, or whether there is a conscious decision to refer to the events in these terms to heighten the drama. Either way, given the import of the situation, it seems plainly to be wrong, and unfair to interviewees as much as to the accused.

…and got a bit claustrophobic in parts.

This may be the public health physician coming out in me, but I felt that the series was very narrowly focused on the case at hand—with a couple of notable exceptions. The series would have benefited from drawing more on similar cases and from aggregated data about many cases. I wanted stats!

I don’t know why it aired before completion…

It isn’t clear to me why Serial started airing before the series was complete. It seems a curious decision, and one with which I’m not entirely comfortable. Hypothetically, if someone had confessed, would the series have continued? Would it have been fair to air a recorded confession prior proper investigation? Would it be fair even to report such a confession? Starting a story which has such a big impact on the lives of all involved without clear knowledge of where it might end strikes me as mildly irresponsible.

I think this changed the nature of the podcast, too—the tone and focus seemed to shift as the podcast went on, in a way which might well be attributable to the media coverage it generated. It started out as an exploration of the limits of reasonable doubt, and ended as an unsolved whodunnit. The former was a more interesting concept, with more interesting stuff to explore, than the latter.

…nor why there were strange gaps in the story.

Relevant questions seemed to go undiscussed in Serial – though it’s possible I just missed them. (Possible spoilers ahead.) It’s not clear to me whether Jay knew where the body was. It’s repeatedly said that Jay was able to show where the victim’s car was, but there’s no discussion of whether he knew the location of the body. This is a bizarre omission given that his story is that he helped to bury the body.

And don’t get me started about that conclusion.

I felt like the podcast got a bit wrapped up in itself by the end. My impression throughout was that the intention was to explore the nature of reasonable doubt. It seemed as though the show caved to externally generated expectation to ‘solve’ the crime in the final episode – an unrealistic expectation which wasn’t met, but was sort of pointed at and talked around. This was a shame. I would’ve liked a much more strident ending that pointed out (spoilers ahead) that – no – we don’t know who committed the murder but – yes – the trial outcome was wrong because of the gulf of doubt. I wanted Koenig to come out fighting about ‘innocent until proven guilty’, not giving a personal reflection on her own personal theories about Syed’s guilt or innocence.

But overall—I can’t wait for Season Two.

There were problems, but—all things considered—I enjoyed Serial. It’s great to hear speech radio done really, really well. I donated towards a second season and will look forward to listening to it. In the meantime, I’m now totally hooked on another This American Life alumnus’s podcast: Alex Blumberg’s Startup (and Reply All, which I actually discovered first). Oh, and This Week in Google, of course. Not forgetting my preferred alarm clock, The Globalist. And More or Less. And… well… all the good stuff.

A number of politicians have recently made absurd statements about the role of the market and profit in healthcare, and specifically in the NHS. In political terms, the two worst culprits are the Labour Party and the National Health Action Party.

When the Labour Party left office in 2010, data¹ showed that roughly 5% of NHS procedures were carried out in the private sector. Under the current Government, as of the most recent set of statistics, this is roughly 6%. It’s just worth bearing those proportions in mind whenever you hear Labour pontificate on the role of the private sector in the NHS. But I digress.

In his Party Conference speech, Andy Burnham asked:

And for how much longer, in this the century of the ageing society, will we allow a care system in England to be run as a race to the bottom, making profits off the backs of our most vulnerable?

I’ll answer that question in a moment. But to illustrate that Burnham is not alone, let us turn to the National Health Action Party.

You may not have heard of the National Health Action Party: it is a well-meaning but misguided Party whose platform—to defend and improve the NHS—is as vague as it is logically flawed. Dr Richard Taylor, co-leader of the party, was previously an MP; he signed an Early Day Motion in support of homeopathy, and praised the use of acupuncture and reflexology in cancer treatment. To date, the party has contested and lost nine elections² with their best result being a 9.9% share of the vote for a single council seat in Liverpool. Again, I digress.

In The BMJ, in reaction to the news that Circle Health plans to withdraw from its contract to run the Hitchingbrooke Hospital in Cambridgeshire, a National Health Action Party representative said:

This perfectly illustrates the difference between the private sector, which seeks profits, and public NHS Trusts … This shows exactly why the market has no place in healthcare.

So, you ask me, what’s wrong with those quotes? They seem like perfectly sensible sentiments to me!

Both of these quotes are simply nonsense. Neither the Labour Party nor the National Health Action Party are campaigning for the removal of profits and the market from the NHS—and nor is anyone else.

Any modern business, be it a hospital or fishmonger, is reliant on suppliers who will draw a profit. The NHS doesn’t manufacture its own light bulbs and baths, nor generate it’s own electricity,³ so people will draw profit from supplying them.

Alright, you might be saying, but that’s not really medicine, is it?

But of course, profits are made on medicine too. Sure, the NHS could manufacture all the medicines it needs—it already manufactures some.⁴ But many medications are under patent. Are NHS patients to be prevented from accessing patented drugs? Of course not: so companies will draw a profit. And the more sick people there are, the bigger the profit there is to draw.

OK, you say, but medicines are a special case.

Except they’re not. Almost every product used to deliver healthcare—from syringes to catheters to implants to surgical tools—will generate a profit, as it is almost all bought in from commercial manufacturers.

Come now, you say, supplies are a red herring. I’m interested in healthcare—a human caring for another human. There’s no profit to be made there!

Oh, but there is. Management of human resources is a tricky business. Often, Trusts will hire in external experts to help with training, planning or management, many of whom will work for consultancies which make a tidy profit.

Everyone knows human resources officers aren’t human, you intone—though I couldn’t possibly comment, I’m talking about a nurse looking after a patient at the bedside. Where’s the profit in that?

The scenario you describe is just dripping with profit—from the agency that recruited the nurse, to the profit on the manufacture of his uniform, to the cut of his pay which goes to the nursing agency he’s working for, to the cut of his car parking fee which is given to the private company managing the facility.

Ugh. You do go on a bit. What’s your point?

Suggesting that the NHS be removed from the commercial market and freed from the pursuit of profit is nonsense. Of course, the internal market in which NHS providers compete with one another could be reformed or removed, but the NHS is involved in a wider external market which is here to stay. The NHS is one of the country’s biggest purchases of goods and services, and each supplier will be doing the best they can to—effectively—profit from the sick.

Even if, for the sake of a thought experiment, we say that the NHS could be isolated totally from the battle for private profit, the end result in terms of the health service alone might not be that different: there would be continual pressure to reduce costs to the taxpayer, which is effectively the same financial pressure as increasing profits to shareholders.

The true argument is about the extent of involvement of the private sector.

Consider privately-employed doctors. Would we trust doctors to the same extent if we knew their interests balanced our interests with profit potential? This isn’t something we have to treat as a thought experiment: most GPs are small businesses and work on exactly this principal with little discernable effect on levels of trust. But, again, it feels icky.

Consider private sector management of whole NHS hospitals. This might look like a step too far: it takes a layer of previously publicly-funded management, who perhaps tried to balance the drive for profits with the best interests of patients, and moves them to the profit-hungry private sector. Yet, the management would always be accountable to commissioners, who would be looking out for the patients: so does it really matter? Perhaps not from the conceptual standpoint—but I’ll admit that it makes me more than a bit uncomfortable. And while a sample size of 1 makes for a poor trial, the fact that the first hospital so-run has become the first hospital to be rated as “inadequate” on patient care does not feel reassuring.

Consider public health campaigns teaming up with well-known brands. Is it okay if public healthcare money inflates Aardman Animations’s bottom line, if using Aardman characters is a good way to get health messages to children? I’m not sure: evidence about cost-effectiveness could sway me one way or the other.

Wouldn’t it be wonderful if we could have a debate on these issues that’s based in the real world, rather than the five-word soundbite world? Wouldn’t it be great if politicians would describe the extent of private involvement in the NHS that they believe to be appropriate, and we could then vote for the Party whose ideas most closely align with our own? Wouldn’t it be peachy if our politicians would stop patronising us all and treat us like adults?

As I said in my last post, the current model of delivery for the NHS is unsustainable. This is a problem that needs statesmanship, cross-party exploration, and—most importantly—tackling by adults.

We’re 120 days from the UK General Election, and I’m already truly fed up with hearing absurd nonsense about NHS spending from politicians of all colours.

Society is ageing. There are 3 people of working age for every person of pensionable age in the UK.¹ A little over two-thirds of working age people work, so there are, roughly, 2 working people for every person of pensionable age in the UK. By 2050—within my working lifetime—this ratio will approach or exceed 1:1.

Mean health spending per annum for a person of pensionable age is currently circa £5,000. That’s exclusively health spending; it doesn’t include social care costs, pensions,² or anything else the Government spends to support the elderly. That £5,000 estimate is rising fast, and will continue to do so.

As the proportion of the population which is of pensionable age increases, and the costs per person of pensionable age increase, this model quickly becomes unsustainable. You reach a point, within decades, when the total tax burden becomes untenable. And before anyone says “but what about corporate taxes?”: these are, of course, paid by people, be they customers, workers or shareholders (which are mostly ordinary people via pension holdings).

Of course, it’s not all about the elderly—the young are getting sicker for longer too. As one of many examples: it’s been postulated that fully 10% of the current NHS budget is spent on diabetes-related care, and the prevalence of diabetes is rising by the month.

I believe passionately in the provision of healthcare free at the point of use. But I also believe that our current model for delivering this is broken. I don’t know how to fix it. This is where I’d like politicians to put forward bold and coherent visions of alternative ways of making this work.

What do we get instead? Monkeys arguing over peanuts. Even the National Health Action Party, whose raison d’étre should be to put this on the agenda, fail to articulate anything resembling an alternative.

Over the course of her term in office, Margaret Thatcher increased NHS spending by an average of 3% a year above inflation. These years are recalled as some of the darkest in the history of the NHS due to the perception of cuts—cuts which were, in reality, simply a level of investment which did not keep up with the rise in demand. The current budget of the NHS in England is £100m:¹ a 3% per year above-inflation rise is £16bn extra funding per year by 2020.

Over the course of the next five years, the NHS estimates a £30bn per year budgetary shortfall if funding rises only in line with inflation.

Consider those two figures. £16bn per year on a Thatcherite scale of investment, £30bn per year needed according to the NHS itself. How do our political parties compare?

• The Conservative Party claimed to be increasing the budget by £2bn in 2015/16 as a “down-payment” on £8bn per year future investment. However, it emerged that only £1.3bn of this was actually new money, and was for the whole of the UK, with Scotland and Wales taking £300m between them. So it’s a £1bn increase. Whether or not the rest of the £8bn will be made from smoke and mirrors—it’s way below what’s needed.
• Labour want to invest an extra £2.5bn per year, which—depending on the announcement—they want to spend on one of myriad things, with seemingly no understanding that money can only be spent once. Not to mention that it’s far, far below the level of investment required to maintain the NHS in any case.
• The Lib Dems have the most generous offer: £8bn per year. Half of what Thatcher would invest, a quarter of what’s needed. They expect NHS ‘efficiency savings’ to make up the shortfall. Where do they think the NHS is “wasting” £22bn at the moment? Perhaps I’ve too simplistic a mind, but it’s hard to see how a reduction in spending of £22bn isn’t a “cut”.

All three parties appear to have reached the same conclusion as me: it is unfeasible to continue to fund the NHS under the current model. Yet instead of tackling this head on, they are arguing over whose inadequate increase is biggest. Each party is complicit in maintaining a veil over the true scale of the problem, and bereft of anything approaching a plan to address it.

I appreciate that saying the current model of delivery for the NHS is unsustainable is a great way to lose an election. It’s a problem that needs statesmanship. It’s a problem that needs cross-party exploration. It’s a problem that needs tackling by adults.

1. The figures used in this post are intentionally rough and ready. They’re based on national statistics, but aren’t exact for a whole variety of reasons to do with stuff like rounding and comparability. I promise it doesn’t matter – the thrust is the same even if the figures are a bit out. ↩
2. Talking of pensions, the entire £100bn budget of the NHS—for people of all ages—is currently matched almost pound-for-pound in state pensions. This surely cannot be sustainable. ↩

A little before Christmas, I told you that I wouldn’t be posting my regular book reviews or weekend reads any more. I gave a vague promise of “plans” for my blog, but didn’t really explain myself. In this post, I’d like to write a little more about my intentions.

But first, of course, it is only polite for me to wish you a happy new year!

http://youtu.be/JuxCfgynbTg

Over the last couple of years, I’ve had a number of fairly long-running ‘projects’ – in the loosest possible sense of the word – on this site. I’ve had book reviews, photo series, weekend reads, and a few others besides. My mum particularly liked “photo-a-day” because she said it let her keep an eye on where I was in the country, and what I was up to!

Part of the reason I set all of these up was to give me an impetus to post stuff. A regular posting schedule generates an expectation of something appearing – albeit more, I suspect, in me than in anyone reading this stuff. I doubt anyone sat and hit refresh every Friday until my reading recommendation appeared…!

But over the last few months, this boxing in and categorisation of stuff has started to feel a bit restrictive. I’ve found myself posting more in places other than my own site – places like Facebook, Reddit, and Google Plus. I’ve caught myself thinking ‘this isn’t a website sort of thing’. And, of course, that’s nonsense – this is my own blog, and it’s entirely up to me what I write. I spend much of my professional life writing serious stuff for serious purposes. My blog has always been my writing playground, so it seems silly that I’ve virtually imposed “rules” on myself.

When I started blogging (over a decade ago – gulp), I wrote about all sorts of things, in all sorts of ways, from a personal perspective. It was something a little more like ‘journaling’ than anything I post nowadays. Not every post was crafted carefully, and, in retrospect, not every post worked. But it was fun; I wrote things to better understand them, to express frustration or excitement, and just because writing was fun.

So when I said I had new plans for the blog, what I really meant was that I was resurrecting the old plans… in the loosest possible sense of the word ‘plans’. Expect quantity over considered quality. Expect more personal posts on a wider range of topics.

In my experience, when someone posts something like this on their blog, it almost always results in a couple of posts, and then a dearth of content. It’s usually a sign of someone being fed up, and making a last-ditch effort to start again – and that’s more true at this time of year than any other.

I hope that’s not the case here. I hope this is a change that will breathe new life into my blog. But I guess everyone thinks that when they write a post like this. I guess we’ll see what happens.