Saturday’s Kids: The decline of Schoolkids with jobs, and the increase in Exam Results.

Welcome to my first blog of 2018. 

I plan to write one blog a month, but look at each issue in a bit more depth.  Over the last year I found that I wanted to go into some subjects in more detail than a fortnightly blog allowed.


I had started writing a blog for January about the UK Labour market part when a friend of mine posted an article on Facebook about the increased numbers of University students graduating with a First.  This feeds into a narrative about the younger millennial generation, a rather unflattering narrative.   Given that my own daughter is going through the University applications process 30 years after I did I thought it would be good to bring forward something that I had planned for February.

For a long time I have been wondering about the sharp decline in the number of children with Saturday jobs.   When I say Saturday jobs I mean any kind of employment while studying including paper rounds, shop work, bar work, etc..   I started working when I was 13 or 14 asa pot collector at Ramside Hall, working my way up to waiter and then barman, running the bar for weddings at the Pemberton suite.    My guess would be that more than half of my year at Belmont had regular or irregular paid work.   

My money went into building a large collection of LPs and singles, buying mod clothes, and running a Vespa scooter.  Even by the 1990s 40% of school children were “earning while learning”. 


Today only 18% of children have Saturday jobs.   Looked at from the employers perspective the decline is even more dramatic.   Employers who want to hire people who are still in education need to register with the Local Authority.   In 2011 Middlesbrough Council issued 101 permits for children aged 13-15 to work – by 2015 this had fallen to 7.  

As a small business this shift is very notable.   The younger the employee the less likely they have been exposed to the world of work, and the more they have to be shown how to behave in the workplace.  The basics of how business works, how to deal with customers, how to solve problems when the boss isn’t around, how to fill the time in on a boring shift are alien experiences for lots of young people.

Some of these changes are due to a fall in demand.  The most popular Saturday job in my era was delivering newspapers.   The reduction in the number of people getting papers delivered everyday was the main reason for the fall in employment permits in Middlesbrough.

The changes in the UK high street have also impacted.  The companies who offered the most opportunities for Saturday jobs were people like Woolworths and BHS, companies who just don’t exist anymore.  Where companies are still trading they are automating jobs like check out assistants reducing opportunities further.   

There has been an attitude shift towards suitable employment for young people.  A friend of mine had a Saturday job at Cheveley Park shops where their main task was selling cigarettes. People don’t buy as many fags as they used to, and allowing children to sell fags and booze is no longer acceptable.

As well as the demand side change there has been a supply side change among young people – the pressure to do well at school is much greater, and there is a lot of anxiety that time spent working and earning should be spent studying.  The pressure to get good grades and succeed at school is radically different to my era, where slacking was pretty commonplace.

As an employer however there is another rather obvious reason not to hire school kids to work on a Saturday.  Under the Modern Apprentice scheme we could hire a school leaver full time on £3.50 per hour. We would even get a grant from the Council in case that pay rate was too much of a burden for us.   It is hard to see why I would hire a nice middle class kid one day a week for £5 per hour, when I can have a permanent employee for less.   Wage rates for under 21s have been deliberately driven down by the Government to such an extent that it is not attractive for kids to take Saturday jobs. 

If this sounds a lot like a 1980s YTS scheme it is because it is a lot like a 1980s YTS scheme.  The terrible pay rates for under 21 Apprentices aren’t particularly well known, and would be a shock to lots of people.

A while ago I wore about trends in drug use.  Not only are young people working less they are doing drugs less too.

In the mid-90s 30% of 16-25 year olds had taken illegal drugs in the last year.  This has fallen to 18%.  We need to be a bit careful because the definition of young people in the drugs survey is different to the definition of young people in the labour market, but there is enough of an overlap to make a comparison. 

The fall in the quantity of drugs is mirrored in the decline in alcohol consumption.  The total number of units of alcohol consumed in the UK has fallen in most years since 2000.  This will come as a surprise to people given the number of headlines about the impact of alcohol on A&E attendances, but we are all drinking less.   Under age drinking has fallen hugely.   Back in the 80s, 62% of children aged 11-15 had drunk alcohol.  Today that has fallen to 38%.    The same is true when we compare the youngest category of drinkers (16-24 year olds) to my generation; Less than half (48%) of those aged 16 to 24 reported drinking alcohol in the previous week, compared with 66% of those aged 45 to 64.   The number of young people who are teetotal is much higher than my generation, increasing the rate of non-drinkers in the UK to roughly 20% of the adult population. 

There is evidence that young people are having their first sexual experiences at an older age however I am reluctant to research this due to the rather obvious problems of using the internet to look for information about young people and sex.   An easier area of statistics to look at is the teenage pregnancy rate, which has fallen from 55 per 1000 population in the early 70s to 23 today.  They have fewer fillings and better teeth too.

As a final statistic about how sensible young people are DVLA records show a decline in the number of young people with driving licenses.  In 1995/97, 43% of those aged 17-20 held a full licence, compared with a low of 27% in 2004 and 35% in 2010.   

Whether these numbers confirm or confound your view of young people depends on what your preconceptions are.   There is however another popular media stereotype about young people that I thought would be worth testing.  In this year’s General Election a large number of young people registered to vote and voted for the first time, boosting support for the Labour Party.  A tiresome number of press articles have been written about the popularity of “oooh Jeremy Corbyn” among young people.   

These stories are rather at odds with most of the research on the subject.  Young people have much harsher attitudes towards welfare, crime and income redistribution than my generation, who have much more typical left wing attitudes. In particular their views towards “benefit scroungers” are very much harsher.  In fact the Labour Party’s shift to the left has coincided with an influx of older members, not younger.  Typical old Labour policies like re-nationalisation of utilities are less popular with my daughters generation than mine.   While partisan pro-Corby websites claim that the average Tory is in their 70s and the average Labour members decades younger the reality is that there is only 4 years between the average age of a Conservative party member and their Labour equivalent (53 to 57).   The rise of Corbyn has made the Labour Party membership older, richer and whiter.

There are 2 key areas where younger voters are different to the older generations; they are much more socially liberal and far more pro-European. 

While all of these generational changes have been going on educational attainment has been increasing markedly, which has caused a huge amount of debate about the dumbing down of British education particularly in newspapers like the Times and the Telegraph.  Every increase in GCSE or A Level results has been greeted by wild claims of dumbing down.

I am instinctively sceptical about these claims.   All of my experience as a student and then a Dad leads me to believe that young people spend more time studying, are more sensible, drink less, and do fewer drugs, and that this is likely to be a very significant factor in improving grades.  

Bloody millenials eh?  Walking round like they rent the place.

There may be a special case around University degree classifications as we went to University at a time when a large number of former Polytechnics and Technical Colleges were gaining degree awarding status or converting to become Universities.   Liverpool now has 4 universities, Liverpool, John Moores and Edge Hill and Hope.   It looks to me the increase in the percentage of students getting a first coincides with the expansion of the number of organisations awarding degrees.

For those who disbelieve me, and who think that education has been dumbed down here are a selection of O Level and GCSE History papers.  Assessing which paper is easier is always a bit subjective, but I found the 1980s paper the hardest, then the GCSE papers, and the older papers by far the easiest. 

If you don’t believe me try them for yourself….

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Hunt vs Hawking. Both are wrong, and things are worse than we thought

For the first time in weeks I have no work this weekend, so I wanted to catch up with a couple of topics that I had written about previously, and which were finding their way back into the news.

For those who follow such things my old pal the Jim Reaper has left Whitehall and returned to Northumbria Healthcare to resume his roles as CEO.   When he left Whitehall he let rip at the oversized centralised bureaucracy that has sprung up since the Lansley reforms.  

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The Conservatives made a big noise about reducing the size of the NHS management cost, but have instead created a dysfunctional centralised system, which adds nothing to patient care.

It is axiomatic that when an ambitious right wing politician announces a change programme that will reduce bureaucracy there will be more paperwork and more centralised administration afterwards.  The more ambitious and right wing the politician, the bigger the pile of paperwork.   

The Trust that Jim is returning to is part of one of the first Accountable Health Organisation pilots:

I am optimistic about ACO’s because they start and unpick the expensive management structures which sprung up around the internal market, and which have been a feature of the NHS from the Thatcher era onwards.   I don’t for one minute think that this is something that Jeremy Hunt would have chosen ideologically, but the shortage of cash in the NHS is driving change in directions that the Government might not have chosen.   The changes to drugs policy I wrote about last week is another example.   

ACOs aren’t universally popular and Stephen Hawking has joined a legal action to try and stop the ACO pilots.   They are the latest management vehicle to be accused of being part of a secret agenda to privatise the NHS:

I don’t for one minute agree with the basis of this legal challenge, and I think that Prof Hawking is badly misinformed here.   The ACO structure doesn’t encourage or discourage private sector involvement in the NHS, it just reduces the costs to the system of maintaining a commissioner and a provider management team.  It is just as possible to use ACOs to reduce private sector delivery as increase it, and I don’t agree that private sector involvement in healthcare delivery is always a bad thing…. it has been part of how the NHS has operated since 1947.   The problem is that the companies who are getting the contracts are among the worse private sector providers while some of the really good private sector organisations are being locked out.    This is giving private providers a bad name.

Apologies for writing so much on healthcare topics.   I intend to revamp the blog in January, and return to more business and labour market issues. 

The reason for so much health policy recently is because I am afraid that the NHS is entering into a period of profound crisis, which neither main political party really has a grip on, and which Brexit will make a lot worse.

To illustrate the impact this slow motion crisis is having I want to return to something I wrote about in the Summer about the impact of austerity on life expectancy.   For some groups in society improvements in life expectancy had stalled and were starting to be reversed.

The latest ONS data on life expectancy is much much worse than I expected.

The ONS are remarkably calm about this, but it looks like pretty much all of the increase in life expectancy since 2017 has been reversed.  The predicted average life expectancy for a man is now below 90 years again.


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It is tempting to suggest that maybe there is a limit to how much we can increase life expectancy, and that the rate of increase will slow as we reach that limit.   Japan, and Scandinavia still live much longer lives than us, and the reverses that we are experiencing aren’t happening there.

We do know that life expectancy links close to wealth inequality.  The richer you are, the longer you live.  The gap in life expectancy between the riches and poorest wards in Local Authorities like Westminister or Kensington and Chelsea are as big as the gap in life expectancy between the US and India.

There is no real need to construct elaborate theories about this.  If you take a poor population and you make it poorer, less well fed, less securely housed, and colder you will increase the rate at which they utilise health resources and reduce their life expectancy.   

For anyone interested in actuarial tables this means that the data which was used to raise the state pension age is now wrong, and the justification George Osborne presented no longer holds water.   I doubt that this will change the decision.  

I will be back next week with a longer blog, and a scary story for Christmas…..

How close are we to legalising drugs? Are the Tories more liberal on drugs than Labour? Will Boris Johnson be remembered as the man who decriminalised cocaine?



I found needles and ampules in my neighbourhood this week.   I live very near a big hospital, which means that it was more likely to be medical rather than heroin, but I rang the Police nonetheless, being a concerned citizen.

For those who don’t know Durham runs the most liberal drugs regime in the UK, not so different to Amsterdam but without the cafes.   The Police and Crime Commissioner has recently visited Switzerland and wants Durham to have the UK’s first legal “shooting gallery”.

Wading through the mass of statistics about drugs is a daunting task.  Police, Home Office, Standing Committee on Drug Misuse, Border Agency, NHS National Treatment Agency, London Mayor and each Police Force all have their own statistics.

What we do know is that overall drug use in the UK is falling.   20 years ago when the Conservatives left power drug use was at an all time high.   In 1997 13% of the population, and over 30% of 16-24 year olds had used illegal drugs in the past year.   Today those numbers are 8% and 18% respectively.  I realise that this is a big shock to people who are used to newspaper stories about drugs and inner cities, but actually drugs policy is showing some signs of success.

Young people aren’t getting high the way they used to. 

The New Labour  administration that came to power in 1997 had a different attitude to drugs to the outgoing Conservatives.  Many New Labour luminaries were from the North East and were associated with a left wing book shop in Newcastle called Days of Hope, known colloquially as Haze of Dope.  While Blair always denied taking drugs, Yvette Cooper was the first serving Cabinet Minister to admit smoking dope, and the then Secretary of State for Health John Reid apologised to the Police after his Protection Officer found small amounts of Cannabis at his constituency home.  After Yvette’s admission a number of other New Labour figures came forward; Charles Clarke, Jacqui Smith, Patricia Hewitt, Alister Darling, Andy Burnham, Harriet Harman and John Denham all admitted historical dopery.

New Labour debated significantly amending the The Misuse of Drugs Act 1971, particularly after the Runciman report in 2000 but bottled it due to their neurotic fear of bad press. 

They did however allow a number of pilots which trialled new approaches to drugs.   The most high profile of these was the effective decriminalisation of cannabis in Lambeth by the then Borough Commander and future “I’m a Celebrity…” star Brian Paddick. 

Less well know, but more significant were the RIOTT trials – Randomised Injectable Opiate Treatment Trials.  Chronic street heroin addicts receiving conventional methadone treatment but who continued to inject street heroin were recruited to 3 NHS centres  (London, Brighton and Darlington).    Patients were randomly assigned one of 3 treatment options: supervised injectable methadone, supervised injectable heroin, or optimised oral methadone. For the first time the UK had offered injectable heroin on the NHS, and the first time the NHS had offered offered opiates since the criminalisation of heroin in 1956 after a campaign by the Daily Mail.   

These trials ran parallel to the introduction of Drug Treatment Orders which were created under the 1998 Crime and Disorder Act, replacing the Rehabilitation schemes under Section 1A(6) of the 1991 Act.   These took several years to get going, and continue to operate despite having a relatively poor record.  Few finish the programme, and even fewer stay away from using afterwards.  The outcomes from RIOTT were by far and away better than the DTO regime. 

In 2004 the Home Affairs Select Committee and and Advisory Council on the Misuse of Drugs published a report into cannabis which led to the then Home Secretary David Blunkett reclassifying cannabis from Class B (which it had been since the 1971 act) to Class C.

I was involved tangentially with some of this work.  I worked closely with Teesside Police on a number of programmes which spanned Police and Health, including the Teesside Drugs Action Team  Many of the communities I worked in were experiencing drugs use for the first time, and I spent a lot of time talking to local anti-drugs campaigns.  Later on I worked for the NHS Trust who ran the Darlington RIOTT clinic.   

There were 2 view points that came through very strongly in discussions with the Police in this era.   

Firstly that the way drugs policy was implemented was discriminatory.  If you were affluent, and lived in a quiet neighbourhood you could take drugs with little or no risk of detection.   If you lived in a  poor, high crime area you were much more likely to be stopped and searched, and be arrested for relatively small amounts of possession for personal use.  This meant that drugs arrests were a feature of poor communities, often with large ethnic minority populations

Lots of people on the left are highly suspicious of the Police, based on very real problems at Orgreave and Hillsborough.  But there were a great many Police Officers with different views, who thought a lot about the way the justice system impacts on communities, and the McPherson report into the death of Stephen Laurence gave them a powerful voice.  I remember vividly walking into the back office in Redcar Police station to find that the Divisional Commander had covered the walls with the MacPherson definition of racism in letters a foot high produced on a dot matrix printer.  A proud moment. 

The other view commonly expressed was the failure of drugs enforcement.  Teesside had a relatively quiet heroin trade at the time, with little of the violence associated with the drugs scene on Tyneside where night club doorman were being shot.  This was a result of a large stable market, plenty of users, and a regular supply through Teesport.   The quietness may have kept the politicians happy, but it was not a good sign.

Barry Shaw, Chief Constable Cleveland Constabulary became the first serving senior Police Officer to come out and publicly say that the war on drugs had been lost, and that the current enforcement regime was causing more harm than good.  He openly called for decriminalisation.

These attempts at moving the debate on drugs forward met with a predictable backlash.    The Daily Mail published lurid allegations against Brian Paddick, which while proven false, damaged his career, and he was moved away from front line Policing.   The Mirror ran a sting against Jack Straw’s son Will, after he sold them a quantity of Cannabis so small it wouldn’t get you through Dark Side of the Moon.

The decision to upgrade cannabis back to class B by Jacqui Smith in 2008 following stories in the tabloid press about Skunk was a huge low point, particularly when it emerged that she had never even met her own chief drugs policy advisor Prof David Nutt.   Wacky backy Jacqui Smith is the only Home Secretary whose name became rhyming slang for a spliff. 

In the same year Ken Livingstone lost the London Mayoral election to Boris Johnson, beating Brian Paddick into 3rd place.   Boris was one of the first Conservatives to admit smoking dope and snorting cocaine, and in his early years as Mayor called for a debate on decriminalisation.    I will say nothing about George Osborne.

Boris Johnson diverted Police resources towards tackling problems with Crack Cocaine across the capital.  This wasn’t a bad idea – crack use was increasing, and it was driving a wave of acquisitive crime and gang violence, including use of knives.   The flip side of this is that resources were moved away from other drugs, including cannabis and powder cocaine.

This took place at a time when there was a shift in powder Cocaine use.  Historically cocaine had been a high price, high purity drug, with limited distribution.  An elite vice.   During the latter part of the first decade of the C20th cheaper, more adulterated forms of the drug had begun circulating, and cocaine had become more widely available demographically.  Effectively a 2 tier market had developed based on price and purity.    

With Police resources targeted towards crack cocaine low level infrequent social drug use attracted little risk of Police intervention.  The problems highlighted by the Police years earlier about the potential discriminatory effects of drugs policing became magnified.

Effectively Boris Johnson decriminalised low level cocaine and cannabis use among affluent Londoners who had little or no risk of being caught.

I tried to source the convictions data to support the shift in resources from powder Cocaine to crack, however this data proved remarkably hard to come by:

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The national Police data set has no data older than the last 4 years, and doesn’t break down to different kinds of cocaine.  The new Mayors priorities don’t even feature Drugs as a headline; stop and search; use of tasers; use of force and hate crime are all higher priorities.

Because so few of us take drugs these days the creeping decriminalisation of powder cocaine and cannabis didn’t really hit the headlines, and I only noticed when I encountered middle aged first time cocaine users chewing their cheeks in a Champagne bar in Durham.

The policy of decriminalisation by deprioritisation spread through Police forces as budgets were cut – some by as much as 30%.   Forces began quietly moving resources away from pursuing low level drugs offenders.  This however simply perpetuated the discrimination built into drugs policy.

Durham Chief Constable Mike Barton called for the complete decriminalisation of drugs in an article for the Observer in 2013.  The quiet decriminalisation of drugs for middle class people started to become a movement to publicly decriminalise drugs across all social groups. 

Durham Constabulary no longer takes action against Cannabis users for low level offences, including growing for personal use.  This attracted a lot of media attention, particularly as the rationale was presented as being as much about lack of resources as progressive policy.   Less well know is that Durham Police offer a similar programme, called Checkpoint, for people arrested for Class A drugs.   Offenders who signed up to a 4 month programme of treatment, drug awareness, restorative justice and community work can have their offences expunged from the record.   Of the 68 arrests made by the Police last year for drugs offences in County Durham only 3 ended with a conviction – all of the others were dealt with through treatment routes.

Avon and Somerset and Devon and Cornwall Police are introducing similar schemes.

One of themes of my blog is the way policies sound great in Westminster and in the press and then are a disaster on the ground.  The criminalisation of heron is a great example of that – usage increased hugely in the following decades.  

The last 2 decades has seen a mixed set of attempts to liberalise drugs policy, which have gathered pace under the Conservatives.  These changes have been driven as much by lack of funding as by instinctive liberalism. It would be mighty convenient for this blog if I could show a neat correlation between drugs policy and drugs use, however drug policy has moved forward in a disjointed manner, and falls in drug use has declined with a similar random walk.   Drugs data is imprecise and scattered across different agencies. Key data is missing, maybe on purpose.  There is however enough of a relationship between declining drug use and liberalisation of policies to make the case for the expansion of the Durham model nationally.   

The Liberaliation of drugs policy might turn out to be one of the biggest social changes introduced by the Cameron/May Government, although this is in the context of a rather thin set of legislative achievements.

And the syringes and ampules?  The Police sent someone rom the Council to clean them up.  No statements taken, no crime number.




Apologies for the lack of blogging. I am on duty running the shop this weekend.  If you would like to pop in and debate any of the issues in the blog, or buy Gin it would be great to see you.

Especially if you want to buy Gin

NHS Managers are great! Lets hire loads more of them.

Very very quietly a long era in NHS history might just be ending.    

I started writing a short history of NHS Management.  My original jumping off point was this article from Warwick University Business School

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Warwick University offer a specialist healthcare management MBA which absolutely isn’t a conflict of interest with this research at all.  Not one bit.  And I am an unhappy former Warwick student which means that I haven’t got a conflict of interest either. 

In any other industry the finding that managers improve performance might not be controversial, but in the NHS this claim would be treated with open derision by any clinician.  NHS Managers are universally regarded as at best a necessary evil, at worse some kind of sinister cult undermining patient care.   I have worked with Senior NHS Managers whose nicknames were POD (Prince of Darkness) and The Jim Reaper, both of whom were very good at their jobs. 

As I wrote it I realised that it was difficult to write about NHS management without writing about privatisation.   A history of NHS management is the history of financial transactions, as much as it is a history of management structures, and the history of NHS financial transactions over the last 30 years has been shaped by attempts to create private sector style market structures in the NHS.

The best place to start with NHS management is 1947.   Healthcare was one of several nationalised industries established by the Attlee Labour Government: Coal mining, railways, road haulage, canals, Cable and Wireless, civil aviation, electricity, gas, and steel.   The majority of these industries shared a similar structure – a centralised bureaucracy with homogenised business units with little or no autonomy under tight political control.  Workers in these industries found their terms and conditions improved but they were offered little or not say in how the businesses were run.   Old fashioned Fordist management techniques which actively disempowered workers in their day to day jobs were common to all.   EF Schumacher’s critique of centralised bureaucracies – Small is Beautiful – was based on his dispiriting experiences with the National Coal Board.

The NHS was set up very differently to these other industries.   Rather than a monolithic public corporation with a command and control management style the NHS was set up as a series of small local units, with little overall political control.   Individual units were allowed lee way to set their own processes and patterns of treatments, and were led by their senior Doctors and Nurses.   James Robertson Justice and Hattie Jaques may have been caricatures but the management structures described in the Carry On films were accurate.

Not all healthcare was nationalised.  The Pharmaceutical industry was kept in private hands, GPs were allowed to remain as independent contractors, and some hospitals like Great Ormand Street were charities funded by the NHS rather than part of the formal NHS structure.  Right from its start the NHS had a mixed economy. 

This wasn’t necessarily by choice,  Nye Bevan had wanted the NHS to be structured in the same way as Steel and Coal, a centralised, wholly nationalised, politically controlled bureaucracy.   

If a bed pan drops in St Thomas’ Hospital it reverberates down the corridors of Whitehall”

He lost the argument, largely because the NHS needed the support of Doctors, who demanded a more empowered, less centralised service.   The final version looked more like the kind of mixed economy of Lord Keynes and Stafford Crips than the National Coal Board.

While this was a compromise I believe that this compromised, flexible structure and mixed economy is one of the main reasons why the NHS survived while the rest of Attlee’s nationalised industries fell into inefficiency, crisis and ultimately Privatisation.  It allowed different varieties of administration to change the balance of public, private and 3rd sector provision without upsetting the overall establishment, while decentralised structures put clinicians in the lead.

Not all on the left agreed and there has been a long tradition from Bevan to Benn to Corbyn of left wing politicians who regard the 1947 establishment of the NHS as original sin, and who want return to a centralised, wholly nationalised service in line with the other nationalised industries of the Attlee Government:

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This structure of the NHS lasted in one form or another from 1947 to 1979.  Calculating management and administrative overheads is hard in a decentralised service, with few formal senior management structures.   Some functions shifted from the NHS to Department of Health and back again which complicates matters.

My best estimate is that by 1979 the NHS spent between 5-6% of it’s total budget on non-clinical management.   

And then came Thatcher.  Contrary to what some left wing politicians and commentators might tell you most Tory MPs don’t want to sell off the NHS or get rid of it.   There are a small number of loud mouths like Dan Hannan who don’t share this view, but they are the exception.  There are however a large number of Conservative MPs who want to shift the balance of NHS provision in favour of the private sector, particularly if it means that profits flow through finance companies they sit on the board of.

NHS Management as we know it dates from the Thatcher era, which probably explains why they are so unpopular.    The 1983 Griffiths report led to 2 massive changes in how the NHS was run.

The first of these was the internal market, a split within the NHS between the provision of Healthcare, and the Commissioning or Financing function.   This has had a number of different names… the internal market, the purchaser/provider split, commissioning, fundholding are all variations on the same thing.    This was supposed to spark off a big increase in the amount of NHS funding flowing to the private sector, but in all honesty it was a dud.   The private sector like stable predictable revenue sources, and the chaotic jumble of patients arriving at GP Surgeries and A&E Dpts doesn’t fit that business model

The other change, which is less well known in the public debate was Unit General Management.  NHS services were chunked into Units each of which had a General Manager.  For the first time the most important decision maker wasn’t a Doctor or a Nurse, but a Manager.   From this point on management and organisational structures got bigger and bigger, and the nomenclature got grander and grander.   UGMs became Chief Executives, with Boards of Directors.  Units became Trusts, then Foundation Trusts, each different variation with a different range of freedoms of action. 

The Internal Market and Unit General Management cost a lot of money.   By the time Thatcher was defenestrated Management costs had doubled to 12%, and given how parsimonious she with NHS funding this was a massive chunk of money.   Once again Neo-Liberalism proves to be more expensive and bureaucratic than the expensive bureaucracies that it replaced.

Incredibly John Major managed to make NHS Management even more expensive.   Major combined the clinical leadership model of pre-83 NHS Management with Thatcher era internal market and came up with GP fundholding.    There is no doubt that GP fundholding was popular with lots of GPs who used it innovate services.  It was, however, the most expensive, most bureaucratic system of NHS management ever devised.  NHS management cost increased to 14% of funding, and huge new buildings were commissioned just to house administrators.  Quarry House on the Leeds ring road is the most startling example of Major’s army of bureaucrats:


There is nothing sinister or totalitarian about Quarry House at all.  Nothing.

In 1997 New Labour arrive and appoint Frank “Dobbo” Dobson as Secretary of State for Health.  Dobbo is the most forgotten of all New Labour politicians, and he presides over the biggest reduction in NHS management cost of all time.  The 1997 Act starts dismantling the internal market,  Fundholding is wound up, and savings in management costs are reinvested in cancer screening.   Most of New Labour’s increases in NHS funding happened in the 2000-2008 period, but Dobbo was able to release money into the service by cutting administrative costs.

This probably seems contrary to the popular narrative about New Labour and management costs best represented by this Daily Mail headline:

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As you might have spotted I don’t have much time for the Daily Mail but this story really is utterly bonkers.   I am sometimes staggered at people’s willingness to believe daft things, but this story really stretches credulity.   This is a photo of Benton Park View in Newcastle, the largest Public Administration site I have ever visited:

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It houses roughly 10,000 Civil Servants, and you can take it from me that it is massive, a vast fortress of bureacracy.   If the NHS really had 200,000+ managers you would need a building that big in every large City in the UK.  I think you would probably spot them.   At the time the article was written the NHS had about 35,000 senior managers, and about another 60,000 admin staff, including people like clinic clerks and medical records. 

Dobson was pushed into a failed campaign to win the London Mayoralty and was replaced by his former Junior Minister Alan Milburn.  By the time the NHS Plan was published in 2000 attempts to dismantle the internal market had gone, and instead a new, Clinically led, version of the Internal Market was promoted, including Primary Care Groups and Trusts.    From this moment on Labour’s policy was to reform the  internal market and make it more clinically led rather than to replace it.  Milburn’s shift in emphasis was certainly due to lobbying from GPs, who wanted to reclaim the system leadership they had lost when fundholding was abolished.   I am sure that there was also lobbying from the private sector, but I can’t say whether or not this was an influence.

There is a lot of noise about the extent to which Milburn and Blair privatised NHS services most of which is a bit misinformed.  Lots of money was spent in the private sector buying up empty operating theatre slots to treat patients who otherwise would have spent a long time waiting for an NHS operation.  I am not aware of any services which were transferred wholesale to the private sector in this period.

The difference between spending NHS money in the Private Sector to deal with the backlog waiting list and the wholesale transfer of services to the private sector isn’t really explained well in the media, and I suspect it suits some politicians on both sides to blur the distinction.

I will declare an interest here – I was one of the NHS managers who did this- I ran a Primary Care Trust whose local NHS Acute Trust had insufficient operating theatre capacity to achieve the targets for reducing Orthopaedic waiting lists.   We did a deal to offer any patient waiting a long time the chance to go to the then BUPA Hospital in Washington while new theatre capacity was built

It does annoy me rather to hear this shift of NHS activity into the private sector described as some kind of sinister creeping privatisation.  I met some of the patients who had suffered for years on waiting lists and I have no doubt that this was the kind of pragmatic action to ease suffering that Attlee would have approved of. 

There was also quite a bit of creeping nationalisation.  The proportion of GPs employed directly by the NHS increased sharply.   We took over a GP surgery and established our own Dental practice to make it easier for people to access care.   Informing our Non-Executive Directors that I had successfully Nationalised Primary Healthcare in Marske was a particular highlight. 

There was also a shift in the distinction between Private and Public within Pharmaceutical R&D – an area which the 1947 Act kept in the Private Sector.   The NHS and Healthcare Charities took a greater role in R&D, filling the gap left as Pharma Companies shifted priorities to areas like Obesity and Erectile Dysfunction. 

By the time New Labour left office the management and admin over head was rising again, driven the increase in regulation after a series of scandals such as Bristol and Shipman.  By the time I left the NHS there was 1 regulator for every 3 managers, and any kind of flexibility of approach was becoming stifled.

Andrew Landsley arrived in 2010 with a mandate from David Cameron that there would be no top-down reorganisation of the NHS.   

He of course then spent £2bn on a top down reorganisation of the NHS, which weakened the Purchaser and Commissioning function to the extent that it was no longer fit for purpose.  The structures which were established by 2012 Health and Social Care Act are currently being reversed to create bigger, strategic NHS management organisations spookily similar to the Strategic Health Authorities that the Act expensively abolished. 

The rationale behind this was pretty obvious – to make it easier for NHS Services to be transferred wholesale to the Private Sector.   There was also a move to make it easier for the private sector to run the commissioning of services, although this was largely blocked by some sensible and strategic obfuscation by Senior NHS Managers.

The costs of market testing, procurement, and legal challenges associated with Landsley’s new model have driven management costs higher still, although it is becoming harder and harder to track management costs from the data the NHS providers as structures are so opaque.   

If I had written this a year ago I would have had only 2 things to say about Jeremy Hunt.  Firstly that he is an inadequate, thin skinned, neurotic weirdo who has surrounded himself with like minded people, and who collectively have allowed a neurotic, micro-managing culture to seep throughout the service.   Not all of the senior managers who have worked for Hunt are in that mould, but the ones who aren’t don’t stick around for long. 

The second is that he has presided over a long era of relative decline.   In order to achieve the savings targets set by the Government the NHS needs a radical reconfiguration of services.  But the radical reconfiguration of services needs a big majority in the House, which the Government hasn’t had since 2010.  Instead the savings have been achieved by in year measures, a long slow reduction in quality, and an increase in mortality.    

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A year later however, things look a lot different.   Stealthily around the country the NHS internal market is being wound up.    No-one is actually telling the public this, instead it is being presented as a way of reducing costs and simplifying organisational structures.   

The words being used to describe this are Accountable Care Organisations, or Strategic Health and Social Care Partnerships.  These are organisational structures based on large geographical areas without an obvious purchaser/provider split.  One of the key figures in all of this is Andy Burnham, former New Labour Health Minister and now Mayor of Manchester, who is using Devo-Manc to unpick chunks of the 2012 Health and Social Care Act, and along with it parts of the internal market.   Manchester, parts of Cumbria, and Northumberland are all adopting aspects of this model.   If it works I expect other parts of the UK to follow suit, there are “vanguards” exploring similar approaches across the UK.

No-one is going to remember Hunt with the affection that Nye Bevan attracts, even though the NHS that he created wasn’t the one he wanted.  But maybe like Bevan Hunt is having to make compromises against his ideology which end up benefitting the NHS in the long run.

The question is – does Hunt actually know about this?  Is he quietly nodding through a radical shift in healthcare policy? Or is he so utterly wrapped up with his team of Special Political Advisors that he has no idea what he is signing up to?

I had lots of fun working as the Chief Executive of a Primary Care Trust, and I worked hard to make Commissioning and the internal market work for patients.   I was able to use commercial mechanisms to reduce waiting times and waiting lists, and improve the quality of care.   But the current commissioning systems are broken, and the cost of fixing them is too high.

Time for the NHS to move in to a new era

Is the NHS Underfunded? What does underfunded mean?

The NHS is underfunded.

This is such a widespread belief, that I don’t know anyone who would challenge that statement.  Instinctively I believe it too, if only because over the last few years the Government has fibbed outrageously about how much it is putting into the NHS which they wouldn’t need to do if funding levels were as good as the Government claims.

It is certainly true that NHS funding is growing more slowly that it was at the start of the century.   I covered some of this in an earlier blog, but it is worth repeating that since 1947 the NHS budget has increased by 4% per year on average above inflation.  A lot of that increase in budget took place in the New Labour years – between 1997 and 2008 the NHS Budget tripled.  At the moment it is growing by 1% above inflation.   This leaves a funding gap of roughly £22bn which the NHS needs to find through efficiencies over the next few years.  This is the biggest saving programme the NHS has ever been asked to find.   At the last election Labour promised a much more better financial settlement for the NHS, but sadly while their funding promises were bigger than the Tories their fibs were larger too.

While all of this is going on the Government continues to promise more and more from the NHS.   More generous Cancer Funding.   7 day services. 

Of course this just tells us the size of the increase, to get a better picture we need to see total Healthcare expenditure compared to similar Nations.   This is the OECD data for 2016:

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This puts the UK in the top 20 nations for Healthcare spending, above the OECD average (9.7 vs 9%) (I have included non-OECD countries like India which participate in the OECD data collection process as well to give the widest range of comparators).

It is probably worth pausing for a moment to stare in astonishment at the USA data which is completely out of step with the rest of the table.  Even after the modest attempts by Obama to restrict healthcare costs and widen coverage the USA is still a total outlier.

If the NHS data looks higher than you were expecting that it because the OECD have recently changed how they look at Healthcare spending to include Social Care spending.   Not all OECD countries have adopted this new measure, which makes a big difference to spend:

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The UK is more generous in funding Social Care compared to other countries than it is in funding Healthcare.

This however just tells us spend.  What we need to know is what this money achieves.   One of the claims frequently made about the NHS is that it is more efficient at allocating resources than pure free market systems like the USA.   Again, instinctively I agree.   There are lots of aspects of healthcare such which can be organised more cheaply and effectively as a State run National service than left to market forces.   Only core OECD countries provide life expectancy data, so I used WHO data for the rest.

This lets us explore the ratio of GDP spend and life expectancy to see how they co-relate:

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Sadly this tells us less than I hoped, as countries with low levels of healthcare expenditure get a lot for their money.  Small increases in healthcare expenditure have a big impact on poor countries, it is a lot more expensive to improve the health status of rich populations, particularly ones with high levels of obesity.

It does however highlight exactly how awful the USA is for healthcare, and that there is a Public Health disaster taking place in South Africa.  You can download the entire dataset and have a play with it if you like – the link is at the end of this blog.

It’s better to look at it as graph, showing spend vs Life Expectancy.   Countries below the curve are getting shorter lives than they are paying for. Countries above the curve are getting longer lives than they are paying for.   Turkey is doing so much better that I suspect that there data is bollocks.

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The UK is doing slightly better than we would expect given it’s level of funding, but only if you look very closely, the advantage is actually slight.  A awful lot of this is do to Social Care funding.   If you went back to the old definitions which excluded Social Care the UK’s performance leaps up above the average.

This is the Commonwealth fund assessment of relative systems performance stripping out the Social Care data:

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We can see that reflected in the data for healthcare resources:

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The averages for Pharmaceutical expenditure are distorted by the USA which spends a staggering $1100 per capita on prescription drugs.   That strange anti-hair loss drug Donald Trump is taking doesn’t come cheap.

The UK delivers an above average life expectancy with below average resources.

Essentially we are getting a good deal from our Health Service, but a much worse deal form Social Care -in fact pretty much all of the efficiency gains that we make from having the NHS are wiped out by the high cost of Social Care. 

The 1947 Act makes a distinction between Health and Social Care.   We all have Social Care needs – we all need to feed ourselves, house ourselves, provide for our own welfare.   We don’t however have the same Healthcare needs.  That’s why there is a difference between Healthcare which is free at the point of use and provided by the state, and Social Care which is only provided in limited circumstances when the individual can’t take care of themselves and is means tested.

At this point I should declare my own position.   I’m a 1947 loyalist. I believe in the principles of the 1947 Act.  I even have my own copy of it, and a copy of the original Beverage report.   

Providing Health and Social Care is expensive, and people intensive.   Politicians regularly claim that technology will make healthcare more efficient such that fewer Drs and Nurses can provide more care.   As I explained a few months back this isn’t efficiency – it is reducing quality:

The costs of providing Social Care have gone up in the UK.   Lots of Local Authorities have got rid of all of their own In-House provision and have left the market to take care of it.   I don’t mind Private Providers delivering Social Care – this has been going on for as long as there has been an NHS.  I do however think that moving to totally Outsourced provision is a mistake as it makes it harder for Local Authorities to set prices and make the market.  Having run Health and Social Care I would never willingly have an all In House or All Outsourced Social Care model.   I am certain that the shift to Local Authorities acting as Commissioners, not Providers of Social Care has made it harder to control costs.

But the big driving force behind the increase in costs is the National Minimum Wage.  Staffing costs are the vast majority of the costs of Social Care provision and the NMW has had a massive impact.  Anecdotally one of the worst sectors for using dodgy employment practices to avoid paying the NMW are in the Care sector.

The debate at the last General Election around Social Care saw the 2 main parties on unfamiliar territory.   The Conservatives proposals to increase the amount individuals have to contribute to their own care, and reduce the amount they can retain to hand down to their families are consistent with the 1947 NHS Principles.   As a 1947 loyalist this makes me happy.   From each according to their ability, to each according to their need.

The opposition to these proposals by the Labour Party puts them on less sure ground compared to the 1947 Principles.  The Labour Party’s plans for a National Care Service is the biggest shift away from the 1947 Act that Labour have made.   As a 1947 loyalist I’m not convinced that this is the right direction at all.   If we are going to invest more Government spending into the Health and Social Care system I would rather it went into the NHS, then be used to reduce the amount people have to contribute to their own Social Care Costs.

This only leaves one question?   Is there any Healthcare metric which doesn’t make the USA look terrible?


If we build more Council Houses won’t loads of Teenage Girls get Pregnant and move into them all?

Apologies that this blog is a week later than I intended.   

This is a bit ironic, as this blog is about waiting lists, specifically housing waiting lists, and the delay in publishing the blog is because of how long I had to wait to find out how long people have to wait for Social Housing. 

I had wanted to write about housing for a while, partly because I wanted to explore the mythology of Teenage Pregnancies and Council Housing, but also because I recently discovered that someone I went to University with had become homeless.  I didn’t understand how a 40 something graduate could become homeless even in a City with as bad a housing problem as London.

I am pretty good at navigating the increasing dysfunctional and bureaucratic remnants of the British public sector, digging out bits of information.  In fact mostly my blogs are about the difference between how things look from Whitehall compared to how they look from an Industrial Estate just outside Durham. 

Housing however almost defeated me.  In fact I still don’t have some of the data that I wanted to write this blog.  Partly this is because successive reorganisations in Local Government and the NHS have made it almost impossible to construct a meaningful time series.

But mainly because Housing is the most awful, the slowest, least responsive, most frustrating, most illogical bit of the British state I have ever engaged with.  Incredible as it sounds it is worse than Universal Credits.  Worse than Job Seekers Allowance.   Worse than the HMRC Excise Movement Control Service helpline.

Worse than the Child Support Agency. 

To give you an example of the kind of mad bureaucracy I encountered – when I approached the organisation who manages County Durham’s social housing to ask for some data they explained that the only way to find out who many Social Housing properties were available would to apply for Social Housing.  They would then assess my housing needs, and tell me how many properties they thought were suitable for me.

This is one of a series of maddening emails.

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It took several weeks to get them to accept that I didn’t want to have my housing needs assessed, I just wanted to know how many properties were available.    Frustratingly each email they sent me had, at the bottom, a list of hard to let properties that they were promoting, in case anyone wants a 1 bed flat in Horden. 

You might notice that I use the phrase “the organisation who manages County Durham’s social housing”.   Local Authority housing in Durham has been transferred out of the Council and into Housing Associations, who between them run Durham Key Options which helps match people to properties.   I have tried to use the term Council House when talking about the past, and Social Housing when talking about the present to reflect that transfer.  Apologies if this is incorrect. 

After 5 weeks of obfuscation I was able to identify roughly 10,000 people currently looking for Social Housing in County Durham.   There are currently just under 800 properties available from Durham County’s Social Housing providers.    Most of the properties are semi-detached houses which were built en masse under the auspices of the County Architect in the 1950s, and are a lot nicer than the houses that private developers are building at the moment, if a bit tired looking.   It was impossible from the data available to identify how long on average it takes to house someone in County Durham – it looks like it varies hugely – if you want a 3 bed semi in Peterlee or Easington there are 100s to choose from.  If you want to live in central Durham there are none available.    Big chunks of Durham City’s Council Houses were bought up under right to buy are now let to Students or post-Grads at the University.    If you are waiting for a house in Durham your wait will be incalculably long.

The fact that it is impossible from the published data to work out the waiting times to go with the waiting list data is very worrying.  As anyone who has worked in the NHS will tell you  – it’s not how many people on the waiting list that matters – it’s how long they are waiting.

Just to complicate matters lots of the people on the waiting list are already in Social Housing, but want to move to a different kind of property, or a different area.   The bedroom tax, which penalises Social Housing tenants with spare bedrooms encourages people to stay on the waiting list, waiting for a house in the neighbourhood with the “right” number of bedrooms to become available.   

The link between Council Housing and teenage pregnancy is one of the most pervasive myths in social policy.   There is a profound belief that teenage girls get pregnant so that they can jump the Council House waiting list.   There is an equally profound belief that being a teenage mum is A BAD THING, although if I was going to spend all of the life on  the National Minimum Wage and I wanted kids, I would have them before I entered the labour market for financial reasons.

I am sure that at some point in the past someone has got pregnant just to get a Council House, however I always thought that this was a classic moral panic – more speeches had been made denouncing it than there were people who had actually done it.

If Council House waiting lists were being gamed significantly by Teenagers you would be able to see a relationship between areas with long waiting lists for Social Housing and Teenage Pregnancy rates.  Long waits should match high rates. 

When I ran a Primary Care Trust I used to point out that the areas around County Durham and Teesside with a very high Teenage Pregnancy rates were the easiest to get a Council House (Easington, Hartlepool), and the areas with the lowest Teenage Pregnancy rates were those where all of the Council Housing had been sold off and waiting lists were infinitely long (Durham City, Yarm).    In fact looking around the North East of England the more Council Houses were sold off the lower the Teenage Pregnancy rate was.  Well done Maggie Thatcher!

I was therefore planning on writing an article mocking the link between teenage pregnancies and social housing when I saw this:

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And this.

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The orange and red lines at the bottom shows Teenage Pregnancies.    

Looking at the UK as a whole the fall in Teenage Pregnancies and the fall in Social Housing waiting lists looks like they match.   My rather neat inverse relationship looks to have broken down in the years since I left the NHS

Apparently after I stopped working for the NHS Teenage Pregnancy rates improved.  This is a co-incidence.   

Before we go any further it would probably help to explain how the Teenage Pregnancy rate is calculated.   It is based on the number of babies born to mothers who were teenagers at time of conception per 100,000 population.   It’s not related to the proportion of babies born to teenage Mums, which has been declining for a century.  The average age of Prima Gravida is now over 30, and has been increasing

That’s is how The Daily Mail can have a moral panic about Teenage Pregnancies:

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AND a moral panic about the growing number of older Mums at the same time.

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The clue to the increase and subsequent fall in Teenage Pregnancies can be seen in this graph:

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Apparently after I was born women across the UK decided en masse to stop having kids.  This is also a co-incidence.  

While the proportion of babies born to teenagers has been declining Britain has experienced a baby boom, with an increase in pregnancy rates across all categories.   As the baby boom has ended, so the the number of teenage mums has fallen.   In fact if we measure the teenage pregnancy rate as the proportion of total babies born to teenage mums the rate has been falling since my Dad was born.

The rise and fall in teenage pregnancy rates was driven by a baby boom across all aged groups, and this increase in fertility had nothing to do with teenagers.  The whole moral panic about the epidemic of Teenage Mums, was just an opportunity for Left and Right to wag their fingers at a social problem, which may not have ever existed.

The Teenage Pregnancy rate, however, wasn’t the only bit of data which looked well dodgy.   The fall in Social Housing waiting lists looked very odd too, certainly it is at odds with most of the headlines in the papers which talk about a housing crisis.   When the coalition government came in waiting list swiftly rose to 1.8m nationally.  Now they have fallen to 1.2m.  

The bulk of the reduction follows the 2011 Housing Act.  Local Authorities were given the powers under this Act to prioritise housing families with local connections.  In reality Local Authorities with a high demand for housing have used this criteria to remove people who don’t have a local link from their waiting lists  – in the most extreme case Hammersmith council cut their list from 8,171 people in April 2012 to just 768 in April 2013. 

I am well familiar with people in the Public Sector gaming the system – manipulating performance data to make a particular organisation look good.  The bogus fall in Housing waiting lists is one of the nastiest, most cynical bits of gaming I have ever seen.   And I worked for the Finance Performance Operations team at Department of Health – “The Evil Weasels”.

Just to add to the mess the movement of housing stock from Councils to Housing Associations blurs the picture even more, making it harder to match the published data to real houses.

There is no doubt that there is a crisis in the provision of housing in all categories across the UK, for ownership and for rent.   We don’t build enough houses, and people like me with access to capital can take advantage of this to make money.

But regardless of the state of the Housing Market things are made worse by the obfuscation, figure fiddling, and bureaucracy from the Housing providers who I encountered.   

This is the same phenomenon that blights DWP and the NHS.  If the Minister doesn’t care whether they tell the truth to Parliament then the Senior Civil Servants don’t care whether the information they give the Minister is true or not.  If the Minister says whatever suits their career, then Senior Civil Servants will tell the Minister what suits their career.  Not all Senior Civil Servants are this cynical, but after years and years of reductions in Public Sector administration those who dislike cynicism have taken the money and left, while those happy to connive have thrived.

And if the Senior Civil Servants don’t care if the information is true or not, then the middle managers who compile the performance data won’t care either.   And the teams in the Job Centres don’t care if the right person gets their benefits sanctioned, just so long as the performance data looks good on the form.

There are lots of good people who work in Housing and DWP who really do care about doing the best for the people they interact with.  But if Politicians care more about tackling imaginary moral panics – Teenage Mums, Benefit Scroungers – rather than addressing the real problems then a culture of cynicism corrupts the whole system.

Which is how a middle class 40 something Graduate ends up homeless.