Rose Tint My World a message for Labour leadership candidates

It was great when it all began

I was a regular Tony fan

But it was over when he had the plan

To invade Iraq and Aghanistan...

Ian Dunt has today written an article on stategy, cynicism and idealism which resonates with a twitter discussion I had yesterday with a fellow Labour Party member on using themes such as Tax Justice to make the Party more electable. To quote Ian's salient point:

Labour seems to have split into three factions: The beige, the red and the white. The beige – represented by Andy Burnham and Yvette Cooper - are mechanical, seemingly without political values, poor to middling media performers and change according to the prevailing political weather. Burnham, for instance, was a Blairite under Blair, a Brownite under Brown and a Milibandite under Miliband. Under none of those personalities did he appear to be a winner. The whites, representing the white flag contingent and currently led by Kendall, have only one tactic: surrender. They are Blairites without any of the intellectual underpinnings. The reds, under Corbyn, are singing from the same socialist hymn sheet as ever, with absolutely no changes, either ideologically or tactically, since the 1970s.

Is it so much to ask that we could ignore the beige, but have a little bit of red and white together? It is possible to get a genuine leftist into Downing Street, but it requires giving up on some of the political purity which seems to motivate Corbyn's supporters.

Ian Dunt ends his article by stating that Jeremy Corbyn and Liz Kendall have a lot to learn from each other if they sat down and listened to each other. I agree with this sentiment.

What I found interesting about the theme of Tax Justice was that Jeremy and Liz were approaching the subject from opposite ends but both were developing the theme: e.g. Liz's request of Margaret Hodge to look at the world of corporate welfare and Jeremy adopting the arguments of Richard Murphy that HMRC should calculate tax revenues using GDP (tax gap in excess of £100bn) rather than their own tax returns (tax gap of £35bn).

The ideas of how we collect taxes and where we spend them are two sides of the same coin.

So my proposal to my comrade was a mixture of cynicism and idealism. I proposed that part of the increased revenues from an aggressive HMRC operating on Tax Justice principles be used to reduce income tax on middle earners up to £100k to 35p in the pound.

We know that the wealthy through various accountancy-inspired schemes pay around 35% of income. The middle classes therefore pay a higher proportion of income. So reducing the percentage paid in tax by this cohort has some notional fairness to it.

I also think we shouldn't forget the lesson of the 1992 election when John Smith's tax proposals scared those who were struggling particularly in the over-heated South-East despite having what seemed reasonable salaries. The same conditions exist today so the Party needs to avoid scaring people with headlines about high taxation.. So by having a policy that supports the 'middle-classes' as defined by the Daily Mail would park the tanks on traditional Tory ground.

Given the increasingly blunt tool that is Income Tax for collecting from high earners, being creative in alternative tax devices to capture from the wealthy would be sensible and show some learning from George Osborne. This would mean giving up the symbolic 50p threshold that defines the Party as being anti-hard-working-families types (pass the sick bucket vicar). Less symbolism, more practical policies please.

Tax Justice with ensuring that the majority benefit from it would cause the Tories some difficulties and present problems to right-wing newspapers as well. It is a policy that is both cynical and idealistic.

So my message to the four leadership candidates is to rose-tint our world with smart polices. Don't dream it, be it...

Evaluating Simon Stevens Dowry

After over a year's wait for a blog, two come along inside a week...

After Tuesday's blog describing the discombobulation of NHS England's Simon Stevens when asked  to consider the concept of fairness, I have found myself continuing to think about the dowry proposal made prior to that moment. It needs to be unpacked as a concept because I think it tells us a lot about the thinking that is happening and thinking that is not happening currently.

If we look at the exchange as transcribed here:


Q63 Austin Mitchell: I just want to pursue the financial imperative. The targets were overambitious for financial reasons: the fact that the money did not follow the patient created local resistance to having the patients. Paragraph 2.24 says, “Meeting the needs of people in the community, who NHS England previously funded in hospital, is a material cost to local commissioners. This can affect their ability to provide appropriate and sustainable care packages. Hospitals subsequently experience significant delays in discharging patients while complex negotiations continue”. This must mean that you can speed up the process through a fairer, better financial arrangement with the CCGs and local providers.

Simon Stevens: What makes this complex is that you have two sets of things going on there. One is that there are a group of people who have been in institutional care for a very long time. When you talk about moving them, as we will be when we are closing some of these facilities, you need to take the old mental health model—we talk about dowries and funding endowments that move with people, and those might be partly with the local authority and partly with the local CCG. If you look at the fact that a fifth of people in in-patient settings have been there for more than five years, those are the sort of folks for whom you are talking about dowries. But for people who have been in an in-patient setting funded by specialist care for three or six months, that is not so much about their ongoing support for ever; that is a moment in time when they are getting something. Distinguishing between those two categories is what we have to do. Some of this will have to be dowry-type arrangements; some will just have to be about a recognition that, actually, this is the CCG’s or the local authority’s funding responsibility, and they will have to step up to the plate.


On a superficial reading, the response made by Simon Stevens could be read as though some thought had occurred before sitting in front of the Select Committee. However there are some jarring inconsistencies of thought occurring that are troubling if we are to take the rhetoric seriously.


The first point of contention comes with the notion of the dowry itself. What exactly will NHS England be funding with this dowry? If the care plans are accurately assessed then the needs of the individual receiving the care package have to be statutorily met. So will any such dowries be providing additional non-statutory needs or is this an implicit admission that the funding streams of CCGs/LAs are not sufficient to provide statutory needs? Is this about the needs of the service user or the needs of service funders?

Then there is the usage of years institutionalised to determine whether the individual requires a dowry as oppose to those expected to be pick-up by CCG/LA spending. How exactly will NHS England determine the qualification for this dowry? Will it focus on enablement? A problem with this is that there doesn't appear to be any evidence for that particular cohort being any more requiring of deinstitutionalisation than those who are there for six months or three years. This isn't person-centred policy based on needs but rather an arbitrary qualification of time that seems to have been plucked out of the air. I can't help but think of Mark Neary's excellent blog and that one of the consequences of his son Steven having spent a year in an ATU has been the need to permission-seek for actions such as going to the toilet as a result of his previous institutionisation.

These questions are particularly important in terms of the concept pursued by the members of the Select Committee of "the money following the patient" (NB for the Select Committee - they are people who aren't ill just because they have LD/ASD). In this context, the dowry concept seems less about facilitating this concept as blocking it. My cynicism would suggest that Simon and his colleagues should be viewing this issue as an efficiency opportunity for NHS England. That isn't a bad motivator in itself as it is more likely to see some change forced through. But for that motivator to work, the incentive needs to be that NHS England retains a sizeable proportion of the spending or in other words ensuring the money doesn't follow the individual. The dowry concept with its years incarcerated qualifier would allow NHS England to retain 80% of its spending. But as I said, I'm cynical.

Indeed with the challenge that Simon Stevens has set NHS England of finding £20bn of efficiency savings and our current cohort of politicians indulging in magical thinking as to bringing together two underfunded services (Health and Social Care) and expecting them to find that their deficit funding disappears, its no wonder that throwing a bone such as dowries occurs.

So I have questions for the Select Committee - what exactly are you attempting to achieve by this notion of "the money following the patient"? What exactly are you funding with it and for what purpose? What does fairness look like to you in this context?

Perhaps I'm being unreasonable to the Public Accounts Committee here but there doesn't appear to be much awareness of how the funding creates action or resistence. Simon Stevens is clearly telling the Select Committee in the answer quoted above that he needs to retain a significant proportion or there isn't the incentive to create change. Hence the discombobulation when Austin Mitchell followed up with the "so you think the funding is fair?" question. Fairness to the individual was the last thing on Simon's mind.

Yet I think Simon has a reasonable argument here given the financial pressures NHS England are under and that if keeping a significant proportion of the spend to allocate elsewhere sees the majority of ATUs shut down then that is a compromise worth making.

What I would advise Margaret Hodge and her colleagues on the PAC is to focus on a more holistic approach to achieving the goals of reducing institutionalisation. Abandon the money following the individual approach and instead split the money being spent on this cohort in three ways: a transitional fund to help CCGs/LAs budgets when any individual moves into the community (this can be graduated for need); developing more community-based specialist mental health services; allowing NHS England to redistribute the remaining savings. The precise proportionality can be debated but lets create incentives to move people into the community and support them when they are there.

The statutory responsibilities on CCGs and LAs to provide care and support  need to be funded properly in themselves. This is where the direction of travel re merging health and social care provision needs to be discussed with honesty rather than magical thinking. Just grabbing part of NHS England's budget as Margaret Hodge suggested to Simon Stevens is also counter-productive as it creates resistence and most likely perverse outcomes. The environment of health and social care post May 7th will be a very contested space regardless of what sort of government emerges.

The need for more thinking about what outcomes you want to achieve and less glib statements that sound good is necessary more than ever. Trouble is I think it will be a long long time before it happens. Perhaps that why this song is in my head this morning.

Simon Stevens Failure is not an Option

Another in a very occasional series of blogs.

Yesterday (Monday 9th February 2015) in the Boothroyd Room of Portcullis House, the House of Commons' Public Accounts Committee chaired by Margaret Hodge met to receive evidence for their inquiry into Care for people with learning disabilities.

As noted on Twitter by Chris Hatton, there was a real disconnect between the mood of the Select Committee and those witnesses appearing in the second half of the hearing. 

Those witnesses were: Una O'Brien, Permanent Secretary, and Jon Rouse, Director General, Social Care, Local Government and Care Partnerships, Department of Health, and Simon Stevens, Chief Executive, and Jane Cummings, Chief Nursing Officer, NHS England.

There was a feisty attitude to the committee members questioning as to why the stated target to move approximately 3,000 Learning Disabled (LD) and/or Autistic Spectrum Disorder (ASD) people out of units following the outrage of Winterbourne View by June 2014 failed.

This was a target that had little bearing on the reality of how commissioning and supply works for LD/ASD people and although traction for the target wasn't helped by the 2012 health reforms, the cultural issues surrounding responsibility and accountability extend further back. It is therefore with a raised quizical eyebrow and copious amounts of salt that I took Simon Stevens commitment to "substantial transition" in the next eighteen months.

This isn't to disbelieve the sincerity of Simon when he states that they "cannot defend the indefensible" but rather that the siren voices of caveats and funding will lure his attempts onto the rocks.

The most significant exchange for me starts at 16:37:30 when Austin Mitchell, whose questioning style is generally languid, starts discussing the failure of the money to follow the LD/ASD individual and that there are disincentives in local authority funding to facilitate the transfer into the community.

This point re local authority funding is vitally important to grasp. To explain, lets use another NHS and local authority cooperation - the transfer of elderly people with care needs out of hospital and into community facilities. This is a constant dialogue between the NHS and LAs with peak demand for flow happening in the winter. To meet the peak demand requires a market response to provide the community spaces and support required and markets respond to funding signals. Yet the funding flow from NHS to LAs operates as if the market capacity responds to a 'just in time' signal. Such an approach is fine if you have automated assembly lines but less so when the largest resource is people. If you are not prepared to pay for excess capacity then time lags will occur and any additional monies thrown at the problem as Jeremy Hunt has done is asking people to retrofit capacity.

So funding flow is important and consistency of funding is important to developing the market capacity required to enable the stated ambitions of Simon Stevens here. Austin Mitchell touches on this when finishing his question by suggesting that the process of transfer could be speeded up by a "fairer" funding settlement.

Simon Stevens response to this is to separate those trapped in the system for a long time (more than five years) and suggests using the dowry model that facilitated the closing of mental institutions in the 1980s with those who been in the system for three to six months where the CCGs or LAs will have to pick up the tab. Note that those who been in the system for 1-4 years aren't being considered in this response.

Austin Mitchell then asks the killer question at 16:39:40: "so you think the funding is fair?"

To use cricketing metaphors, this was the equivalent of a medium paced mid-70s mph trundler bowling a 90+ mph throat-high bouncer that Mitchell Johnson would have been proud of. Watching Simon Stevens body language disintegrate faster than an English batsman facing Mitchell Johnson was quite amusing.

Simon then pulls himself together with the cop-out phrase "its an accident of history". Ladies and gentlemen - welcome to the bullshit zone.

I have to thank Austin Mitchell for asking the right question here as it exposed the thinking here as being limited to "Houston, we have a problem". I don't knock the acknowledgement as the journey has to start with this step but its clear that the stated aspirations as reported by David Brindle haven't remotely been thought through.

This is why two and a half years down the line, work around pooled budgets remains at the starting gate when discussed at the PAC yesterday. A fair settlement starts with what it means to live as a LD/ASD person in their community and to live life to the full. Not as Jane Cummings suggests "as normal as possible" but to live a messy life of their choosing. Any funding settlement needs to follow and facilitate those principles. Its why campaigns such as the LBBill are so important - these need to be legal rights. Those committee members agreeing with a rights-based approach should take note.

My lasting impression of yesterday was that any thinking around this was couched in terms of the conflict of funding streams between health and social care rather than cooperation. The contested space that is the Better Care Fund which is being used more to retain existing LA services than developing new cooperative working as the NHS resents the top-slicing occurring as they experience real terms cuts to their budget. Against this background, it felt as though costs were expected to be pushed from one part of the system to another. Any idea of "fairness" in funding was therefore a shocking concept.

The top-down instruction to get people out of ATUs isn't a bad thing but we need to pool our intelligence to design the mechanisms properly else we'll Heath Robinson the process and create problems down the line. So thinking of Apollo 13 again, this scene resonates somewhat...