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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.

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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.

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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.

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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.

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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 2,300th post was filed under: Politics, .

News organisations are wrong about A&E waiting times

Hospital surgery corridor

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:

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.

This 2,293rd post was filed under: Health, News and Comment, Politics.

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.

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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 2,291st 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 2,289th post was filed under: Health, News and Comment, Politics, , , , .


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