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So far, Cameron is winning the TV debates debate

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.

exposure of a product

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.

This 2,292nd post was filed under: Election 2015, News and Comment, Politics, , , , , , , .

The private sector will always be involved in the NHS

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.

health care industry

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.


  1. Hospital Episode Statistics: the set of data that describes what happens in hospitals across the NHS in England. They’re not perfect by any means, and lag quite a way behind real time, but they’re the best we’ve got. 
  2. The Eastleigh by-election, the London region in the European Parliament election, and seven local election seats. 
  3. Actually, I have worked in a hospital that generated a lot of its own heat and power. They had pages and pages of information about it on the hospital intranet. As a junior doctor, I never got time to read it.  
  4. The NHS manufacturers relatively tiny amounts of “special order” medication that isn’t available commercially. One of the units that does this work is based here in Newcastle, a stone’s throw from the site where William Owen first produced Glucozade as a special pharmaceutical product to aid recovery from common illnesses some 88 years ago. It was later sold to Beecham’s, renamed Lucozade, and is now everywhere, despite the fact that—to this blogger at least—it tastes vile. 

This 2,290th post was filed under: Health, News and Comment, Politics, , , , .

Politicians talk nonsense about NHS funding

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. 

This 2,289th post was filed under: Health, News and Comment, Politics.

Ten statistics for International Men’s Day

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19th November is International Men’s Day. The politics of International Men’s Day are often portrayed as complex, and many people seem to be of the opinion that it’s little more than a “me too” event to match International Women’s Day, or – at worst – some sort of anti-feminist fest.

But, for a moment, put the baggage to one side. It isn’t reasonable to argue that either men’s or women’s issues are more important – both are humanity’s issues, after all. But perhaps this is a good day to reflect on some of the challenges which are, in today’s society, more greatly burdensome for men than for women – just as we do the converse on International Women’s Day.

In that spirit, and without further comment, allow me to share ten statistics on which we can all reflect today.

  1. A man ends his own life every two hours in the UK; three-quarters of those who kill themselves are men.
  2. Men are 35% more likely to die of cancer than women – and if diagnosed with a non-gender-specific cancer, are 67% more likely to die from it.
  3. 90% of homeless people in the UK are men.
  4. 95% of the UK prison population is male.
  5. Girls consistently outperform boys in education, and young men are 25% less likely than young women to get into university in the UK.
  6. Young men are more than twice as likely as young women to be unemployed in the UK.
  7. Men account for 96% of work-related deaths in the UK.
  8. In England and Wales, men are twice as likely as women to be victims of violent crime, and twice as likely to be murdered.
  9. In the UK, 40% of victims of reported domestic violence are men, yet there are few services and little funding to support male victims. As a result, male victims are substantially less likely to access professional support.
  10. On average, men die four years earlier than women in the UK.

Male generations

This 2,284th post was filed under: News and Comment, Politics.

Ebola and big data: Call for help

This Economist article on the potential use of mobile phone tracking data in the West African Ebola outbreak us quite interesting. I’m not nearly expert enough to make any meaningful commentary on how useful or otherwise such data would be, but it seems unhelpful for networks to block data sharing.

But – and here’s the rub – there’s a really distracting logical flaw in the middle of the article. The Leader claims that tracking based on incomplete mobile phone data is “better than simulations based on unreliable statistics”.  Yet the Leader also describes the mobile phone data as incomplete and imperfect, which means it, too, will be a simulation based on unreliable statistics. And, besides, if they’re bemoaning the lack of availability of the data in the first place, how do they have the foggiest clue as to whether it will be better or worse?

I expect better from Economist Leaders!

This 2,280th post was filed under: News and Comment, Rants, , .

Why I won’t subscribe to Kindle Unlimited

Amazon has just launched Kindle Unlimited in the UK. I read a lot of books – but won’t be subscribing. Here’s why.

Man reading book surrounded by falling letters

Amazon launched Kindle Unlimited in the UK a few hours ago. Kindle Unlimited, which has been available in the States since July, allows subscribers to pay a monthly fee (£7.99) to access 650,000 eBooks and an unspecified number of audiobooks without further payment.

I read a lot of books, mainly on a Kindle. I dread to think how much I spend each month on books, but it is most certainly more than £7.99. So, when Kindle Unlimited launched in the US, I was pining for a UK launch. This came up in a conversation over a drink with a non-techy friend: “What, like a library?” she asked, as I described the service.

The question was as barbed as it was sarcastic, and it struck a nerve. Some sliver of my Council Tax already funds the ability for me to borrow from an enormous collection of physical books, eBooks and audiobooks via my local library. It is vaguely absurd to pay a second time to access a more limited library.

So I set myself a challenge: ditch the Kindle and start using the library.

The first barrier was to discover that I don’t own an eReader compatible with the formats available from my library. But this wasn’t really a problem: I chose to read eBooks mainly because they are cheap, available ‘over the air’, and take up no space in my house. Library books are almost as good: they’re free, take up no space in my house, and are available to collect from the library.

My local library, in common with others, has a great click-and-collect service: I request a book online; they dig it out from whichever library branch or store it is in, whack it on a ‘collection’ shelf near the door in the most convenient branch for me, and notify me that it’s ready to collect. I can then pop into the library during my commute and swap books using a self-service machine. It takes less than sixty seconds from entering the library to exiting.

Of course, not all books feature in the library’s stock. Rather than have the library source these from elsewhere, I’ve bought my own copies; the joy of reading physical books from the library has convinced me to buy paperbacks. So much for saving shelf-space.

The last ten books I’ve read would have cost, in total, £66.89 in Kindle format. Only two of them appear to be among the 650,000-book Kindle Unlimited selection. All but two were within my library’s selection: I paid £9.09 for one of these two in paperback, and borrowed the other by post from the BMA library. Hence, I saved £57.80: an 86% discount.

And so (tl;dr): Amazon’s Kindle Unlimited package made me re-evaluate how much I spent on books. It made me realise the value of my local library, and has lead to me using Amazon far less, and saving myself a small fortune in the process.



If you fancy reading this same post in a slightly different format, it's also available on Medium.

This 2,273rd post was filed under: News and Comment, Technology, , , , , .

Amazon’s Fire Phone is about the ecosystem, not the phone

FirePhone_Hand_Firefly-Icon

In 2013, Apple sold something of the order of $10bn of apps, making profit of the order of $3bn. Estimates suggest a further $2bn profit from iTunes sales. These figures suggest that these two classes of digital content alone account for nearly 14% of Apple’s profit.

As is widely reported, the Google Play store on Android has higher download figures, but brings in only about a third of the revenue of Apple’s App Store (though revenue is growing faster for Google than Apple). The trajectories suggest that Apple’s closed ecosystem will become decreasingly relevant in revenue terms over the coming decades – though I’m sure Amazon would open an iOS app store in moments if permitted to do so.

I suspect that Amazon is playing into the smartphone market with an eye keenly trained on these figures. I buy Kindle books, rather than iBooks or Google Play Books, because I can read them anywhere, on many devices. For Android users, this is already partly true for Amazon’s App Store: apps bought on Amazon’s store can be used across Android, FireOS, and Blackberry devices, yet Google Play or Blackberry app sales are limited to their own ecosystems. Since I own a Kindle Fire, I tend to buy on Amazon’s store even if buying for my Android phone.

Amazon’s move into the smartphone market makes this all the more compelling: if I might, at some point in the future, own a non-Android phone, then I would be crazy to buy apps for my Android device from Google rather than Amazon… especially as Amazon Coins generally make the same apps cheaper via Amazon than via Google.

Amazon’s strategy for digital content has (almost) always been to capitalise on cross-device compatibility. I doubt Amazon expects huge sales for it’s phone: I think it is the digital content market it wants, and that the phone is merely a means to an end.



The image at the top of this post is an Amazon press shot.

This post also appears on Medium.

This 2,252nd post was filed under: News and Comment, Technology.

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