The healthmatters blog; commentary, observation and review
Financial pressures threaten to block a majority of UK adults from a choice of social care services to suit their individual needs, according to new research from national homecare provider Prestige Nursing + Care which sheds new light on the extent of the escalating funding care crisis in the UK.
- Nearly three-quarters (72%) of people who expect to need social care will have to make do with whatever they can afford, with just 27% expecting to have financial freedom of choice
- Majority feel the state rather than individuals should fund care provision, despite cuts to social care budgets
- But in reality, only 33% of future recipients believe government will provide for them, compared with 51% who currently receive care
- 30% have no idea how they will fund care; and 42% of current recipients feel they cannot afford sufficient care
- More people are willing to pay for gardeners and personal shoppers than professional carers
Stark reality of a lack of choice
Nearly three quarters (72%) of people who expect that either they or a close family member will need social care* in the next ten years are resigned to having to make do with whatever they can afford, even if it is not what they would prefer or best suited to their health requirements.
One in three (30%) who expect to need care have no idea how they will pay for it. Barely a quarter (27%) believe they will be able to pick and choose from care services without worrying about the cost.
Only one in three (33%) believe the government will provide for them or a family member if they require care in the next decade: significantly lower than the 51% of current care recipients and their families who say they currently receive government funding. The contrast highlights the fact that, while state-funded care services are already stretched, the future prospects look even starker in light of the UK’s ageing population and continuing pressures on public spending.
Among current recipients of care and their families, the majority (69%) feel the care they receive is good value for money, yet 42% report that it is insufficient for their needs and that they simply cannot afford more. More than one in ten (13%) feel that the care they or their family member receives is not delivered how or where they want it to be.
Care costs still seen as a government responsibility
Despite doubts over the availability of government funding, Prestige’s findings show that the majority of UK adults retain the view that social care funding should be provided by the state. Half (51%) feel this should be universal while 36% support means tested care depending on individual needs.
Barely one in ten people (11%) believe they should have to use their own savings and assets or that family or friends should have to help out with paying for care.
Similarly, nearly three in five (59%) believe that care workers’ services should be available to the public free of charge, with just 41% saying they would be willing to pay if they needed them. The findings suggest that people are less willing to fund their own care needs than a variety of other services, including taxi drivers, gardeners, cleaners, personal shoppers and lawyers. Only doctors, dentists, surgeons and physiotherapists have fewer people willing to pay for their services [see table 1].
Table 1: Which of the following services would you be willing to pay for if you needed them?
However, the reality of the care crisis facing the UK is that many people will find themselves having to pay for their own care. People with more than £23,500 in savings and assets have to fund their own social care in England. Plans to raise this threshold have been shelved until 2020 as the Government struggles with care provision for growing numbers of vulnerable elderly people. Recent research from Age UK also suggests that cuts to care funding mean that 1.2 million elderly people don’t receive the care that they need: an increase of 48% since 2010*.
Despite the fact that a growing number of people face having to fund their care privately, many are unprepared to do so. Nearly two in five (38%) people say it is not realistic to save up and pay for care while also saving for retirement, and a further 40% say the same while raising a family.
Jonathan Bruce, managing director of Prestige Nursing + Care commented on the findings
“It is worrying to see that so many people do not know how they will pay for care and that a majority do not want to pay for a carer. The expectation that care is free at the point of use for everyone is understandable, but the reality is that the sector is under severe financial pressure, and more and more people are likely to have to fund care privately without relying on Government support. The inconvenient truth is that, in order to receive the quality of care we all desire, it is becoming increasingly necessary to make a significant contribution towards it.
“It’s equally troubling that so many people say they will be left having to make do with whatever level of care they can afford, as getting the right care makes an enormous difference to a person’s wellbeing. If the model of UK care provision is going to become increasingly reliant on self-funding, it is hugely important that people are made aware of these costs early on and supported to make adequate provisions.
“Good quality care rests on skilled professionals to deliver it, and without sufficient funds, it will be impossible to attract the workers needed to meet the growing demand for staff. There is a skewed sense of value at play when it comes to paying for professional services, and as a society, we also need to reappraise attitudes towards the vital services that care workers provide.”
FirstCare, the absence management specialists, predict that this December will see UK workplace absence hit a new high. Across the UK, the company predicts, a total of 23 million working days will be lost in December, delivering a huge knock-on effect to both UK productivity and increased pressure on the NHS.
- Increase will result in 4.6 million days lost in December
- Coughs, colds and flu remain at the same level as 2009
Importantly, this significant increase has been driven by mental health issues becoming the most common cause of workplace absence in the UK, not the traditional issues of seasonal illness and musculoskeletal injuries. In total, FirstCare predicts that 4.6 million working days will be lost to the UK economy in December as a result of mental health issues – an increase of 13% in the last year alone. In contrast, coughs, colds and flu and musculoskeletal injuries have remained broadly constant for the last seven years.
This worrying trend is set against a backdrop of absence continuing to rise year-on-year since 2011, bucking a 20-year trend of decreases. In that time, mental health issues have increased by 71.4% since 2011, with FirstCare predicting that, if the current trend continues, 2017 will be the first year that mental health issues are the most common reason for workplace absence.
Anecdotal evidence from FirstCare suggests that mental health issues are exacerbated by the increased pressures on finances and difficulties in balancing work and family life at this time of year. This goes against the widely held belief that seasonal costs and colds, plus over exuberance at the office Christmas Party, are to blame for people’s absence at this time of year.
Commenting on the findings, David Hope, CEO of FirstCare said: “Many of us look to the festive period with great anticipation, filling our calendars with work Christmas parties and gatherings with friends.
However, we should not forget that for some it is a highly stressful period. Many people feel increased financial pressures and find it more difficult than usual to balance work and family life. These are not new triggers for mental health problems developing, but become very acute in December.
Employers should be alert to this, and spot the signs of mental ill health early, before it develops into a long-term condition. Providing appropriate support for employees during this period will help to avoid disruption to work streams and projects, and to other members of staff who will be impacted by colleagues taking time off due to mental ill health.”
With Christmas just under weeks away, money worries has been revealed as the single biggest cause of stress for UK adults, according to new research.
- Worrying about money causes 33% fall in wellbeing scores
- 52% wellbeing divide between society’s most and least financially confident
Money worries were found to cause the biggest swing in wellbeing scores – creating a 52% divide between the most and least financially-confident people in the country. Other factors significantly impacting wellbeing include the quality of personal relationships and mental stimulation – causing 50% and 48% swings in wellbeing scores respectively.
The report from leading health and wellbeing charity, Central YMCA, surveyed a nationally representative sample of 1,000 UK adults and uncovered that financial woes reduce overall wellbeing scores by a third.
The average Brit spends roughly half their monthly pay on presents at this time of year, according to Nationwide’s 2016 Christmas Spending Report. The same report also found that one in three UK adults regret how much they spend over Christmas, while up to a fifth are left suffering financially for three months or more.
Commenting on the findings, Rosi Prescott, chief executive at Central YMCA, said:
“As we move into what is both an expensive and stressful time of year, it’s likely that money worries will be heightened over the Christmas period. The financial stresses felt by people right across the country are symptomatic of the ever-growing financial inequality in the UK, and these worries and woes are enormously damaging to our overall wellbeing – affecting how we feel about ourselves and our lives.
“At this time of year, it’s important we try to strive towards a healthy balance of mental stimulation, physical activity and positive relationships – all which deliver a significant boost to how we feel about ourselves. Christmas should be seen as an opportunity to improve our wellbeing – reconnecting with relatives and friends, where we can, and encouraging those positive and healthy relationships.”
In total, the average Brit scored 6.13/10 on an index for their overall wellbeing.
For the full report findings please visit: http://www.ymca.co.uk/
New research produced by an audiologist at charity Action on Hearing Loss has highlighted the important role medical professionals can play in encouraging people with hearing loss to take action and get hearing aids.
The research, Experiences of hearing loss and views towards interventions to promote uptake of rehabilitation support among UK adults, sought to identify interventions that would successfully encourage the three fifths of those with hearing loss who could benefit from hearing aids but don’t have them to seek help.
Crystal Rolfe, an audiologist who is Head of London and the South East for Local Engagement England at Action on Hearing Loss, conducted the research as part of her MSc in Health Psychology at University College London.
She said: “While there is a huge body of evidence demonstrating the effects of the loss of hearing has on health and wellbeing, it still takes people an average of 10 years to take action and get hearing aids. This research demonstrated the enormous amount of stock many people put into the advice and expertise offered by trained medical professionals such as nurses and audiologists, and found that if they are proactive about raising a loss of hearing during consultations this plays a significant role in reducing this time.
“With 11 million people in the UK living with a loos in hearing – a number set to increase to 15.6million by 2035 due to our ageing population – it’s more important than ever to proactively address it. Hearing loss is associated with poorer health-related quality of life and depression and an increased risk of dementia, encouraging greater uptake of hearing aids is a cost-effective intervention that will make a huge difference.”
Action on Hearing Loss recommends that medical professionals emphasise the benefits of managing a loss in hearing early before using a hearcheck screener or similar tool alongside otoscopy; if the patient has a hearing loss they then need to be referred onto an audiologist.
The charity hopes the research will encourage GPs and medical practitioners to proactively identify and screen patients for hearing loss.
For more details on what GPs can do for patients who might have a loss in hearing to visit
To take a look at the full paper, please visit
In November 2015 junior doctors in the National Health Service in England voted to take strike action if the government did not change its mind about a new contract, which had been debated for the previous two years. Just over 37,000 junior doctor members of the British Medical Association (from a workforce of around 55,000) were balloted, 76% responded and 98% of responders voted to strike, an expression of militancy on an unprecedented scale in the UK’s public sector. The dispute continued for almost a year, with repeated walk-outs and bouts of negotiation. Pickets outside hospitals made for good media coverage and became a focal point for public support. The strike collapsed in September 2016, after plans for escalation of the conflict were made public. This review of the dispute attempts to explain the course of the dispute and the causes for its defeat.
The course of events
The dispute over the junior doctors’ contract had been brewing for two years, out of public sight, before escalating and spilling out of the hospitals. The first strikes were scheduled for early December 2015, but were postponed after talks about the contract began with NHS Employers. These talks broke down in January 2016, and the first day of industrial action took place on January 12th, with junior doctors providing only emergency care for 24 hours, other staff doing the routine outpatient clinics, ward rounds and planned surgery (some of which was cancelled). Pickets outside hospitals carried banners about saving the NHS, and making the NHS safe for patients, and being treated without respect by the government. The Secretary of State for Health, Jeremy Hunt, became a hate figure for the medical profession, and public opinion sided with the junior doctors.
Further action was suspended by the BMA on January 19th to allow further talks, which also failed. A second day of industrial action, similar to the January strike, took place on February 10th, prompting the government to announce the imposition of the new contract in August 2016. Two-day strikes, took place on March 9th & 10th, April 6th & 7th, and April 26th & 27th. In the first two junior doctors maintained emergency care but this was withdrawn in the late April strikes, during which hospital consultants stepped in once again to provide the full range of NHS services. Talks with the government restarted on May 7th through the Advisory, Conciliation and Arbitration Service (ACAS) and on May 18th ACAS announced that agreement on a new contract had been reached.
The BMA recommended the new contract to its junior doctor members, but 58% rejected it on July 5th in a 68% turnout. The government announced that the phased introduction of the new contract would begin in August, and the BMA’s junior doctors’ committee prepared for more strike action – for five consecutive days each month, from September to December. Dr Yannis Gourtsoyannis, a member of the BMA’s junior doctors committee (JDC) was quoted by the Daily Telegraph (12/8/16) as writing:
‘It’s time to dust off our picket armbands. An escalated fight is on. Theresa May will reap what her predecessors have sown. The following two months are crucial for the Conservatives…We are about to throw a massive spanner in their works.’
He outlined plans for repeated and crippling strikes, increasing pressure on NHS services as winter approaches in ‘an escalated fight’ to get ‘more and more’ out of the Government, and to wage war on its policies. He suggested tin his message to junior doctors that future strikes would have a still greater impact.
‘It’s the trade union dispute of this century. That’s no exaggeration. This is about to be ratcheted up by an order of magnitude,’ he wrote.
The trades union dispute of the century lasted only a few more weeks. The first five day industrial action was called off in August after the BMA was contacted by many members who saw the planned action as disproportionate, and on September 24th the BMA announced a suspension of any further industrial action in England. This followed negative feedback from doctors, patients and the public, and discussions with NHS England about the ability of the NHS to maintain a safe service if the industrial action planned for October, November and December were to go ahead.
What triggered this dispute, in which a large part of the NHS’ medical workforce withdrew its labour, whilst branding itself as saving the NHS? And why did the momentum of the dispute run out when it did? This review of the dispute argues that three conflicts were rolled into one, making the dispute difficult to settle but also impossible to sustain. The conflicts were over the details of overtime pay in a new contract specific to doctors in training, the strains currently experienced by the NHS due to government limits on its funding and the pressure for ‘7 day working’, and the impact of medical work on doctors who are developing from novice status to becoming competent practitioners.
There are four parts to this review. The first describes the workforce and its contract with the NHS, touching on the idea of a highly-paid ‘precariat’. The second sketches the working environment in the NHS from Blair’s government to May’s, including the evolution of the labour market and the drive for a ‘7 day NHS’. The third discusses the nature of the work itself, emphasising the effects of ‘immaterial labour’ on the medical workforce. Part four outlines the strategy and tactics of the junior doctors’ campaign, exploring why the strike movement was popular but unsustainable, drawing on LeGrand’s description of Knights & Knaves in medicine, and the idea of a ‘drawing out battle’ as guides.
Part 1: The workforce and its contract
Junior doctors are doctors in training posts, on their way to becoming consultants or general practitioners. They remain ‘junior’ for between 4 and 10 years, depending on the specialism and their own circumstances, particularly part-time working. They are allocated to the training posts by ‘Deaneries’, bodies responsible for overseeing training in the NHS. This allocation of posts can separate couples, and is unpopular with doctors (because it limits their choice of workplaces) whilst being popular with the NHS (because it fills posts). Their basic annual salaries are in the range £23,000 to £40,000, before overtime and depending on experience.
Junior doctors have always worked long hours. In the 1970s an 80 hour week was common, and overtime (after 44 hours) was paid at one of third normal time. Not surprisingly, such exploitation was challenged in a three month industrial dispute in the winter of 1975/6. The result was a commitment by the NHS to reduce hours, and a somewhat improved pay deal that broke the then Labour government’s pay policy without either profession or government admitting it.
Progress in reducing hours of work was slow. Shorter working weeks meant not only recruiting more junior doctors but also creating more (expensive) consultant posts for them to graduate into. More junior doctor agitation in the 1990s led to the ‘New Deal’ contract, introduced in 2002. This contract was designed to reduce junior doctor hours in a phased way by making overtime expensive for the hospitals employing them. It was punitive towards employers and financially beneficial to some junior doctors, mainly those working frequent long shifts. It was assisted in its aim by the European Commission’s Working Time Directive (introduced in 1998), which specified hours of work, work breaks and recovery time.
The ‘New Deal’ contract
The New Deal contract was built around pay bands. The chart below over-simplifies a complex pay arrangement, but gives a flavour of the financial rewards (to the doctor) of out-of-hours work. The normal working week was defined as 7am to 7pm, weekdays; out-of-hours work began at 7pm on weekdays and included all Saturday and Sunday. A junior doctor working 56 or more hours per week, on average, would double his/her salary. The basic salary increased each year, automatically.
Between 40 & 48/week on average with high frequency out of hours work
As for 1A, but with medium frequency out-of-hours work
As for 1A, but with low frequency out-of-hours work
Between 48 and 56/week on average with high frequency out of hours work
Between 48 and 56/week on average with low frequency out of hours work
Over 56 hours/week on average
New Deal banding was applied to a group of junior doctors in a rota, rather than to individual doctors, for reasons of administrative efficiency. A snapshot of working hours was taken regularly across the whole rota, rather than counting the hours of each doctor for the entire rota. This also cancelled out any individual variations in working time to across the rota. However, this also meant that any changes in banding would apply to all doctors on that rota. So, for example, paediatricians in training would all be on the same band, even if their work was slightly different, with some in the maternity unit and some on the children’s wards. The hours that they actually worked would be captured in the snapshot.
The rules about maximum length of duty period and minimum length of time off duty applied one hundred per cent of the time. A single breach of these rules during a snapshot could make the whole rota non-compliant. In principle, if a single doctor in a Band 2A rota stays at work late or starts early, logging more than 56 hours per week, the result could be the application of Band 3 payment rates to all the doctors on the rota. Every doctor on the same rota would get double pay, even if they had not worked beyond their time limit. The same could occur in any of the Bands.
The New Deal contract was an hours-based rather than a professional contract, focused on working hours, rest time and pay. The system ensured that doctors were paid appropriately for the number and pattern of the hours they work. The use of punitive overtime pay to incentivise reduction in working hours was successful. Since 2007 less than 1 per cent of junior doctors in England have received Band 3 payments. In 2015 the current average extra payment for junior doctors across England was approximately 45 per cent of basic salary. This reduction in hours had been possible because of the increase in the numbers of junior doctors, by an average of 4.5% per year in the first decade of this century. However, because doctors in training were working considerably fewer hours, their average earnings had declined correspondingly compared to previous generations.
A new contract is called for
NHS Trusts did not like the Banding system because it was unquitable, opaque and open to abuseii. Banding could cost them a lot of money if they end up paying a whole rota extra because one member of it has worked beyond their band limit. It created adversarial relationships, made training posts with a higher banding more attractive – which skewed the labour market – and discouraged professional ways of working. Disputes between NHS Trusts and employees about banding could break out when the working hours snapshot was taken, because so much was at stake financially. Automatic annual pay increases were disliked by NHS Trusts because the increment was not dependent on demonstrably increased competence. All this is added to the administrative problem of organising work rotas around complex rules that governed break periods, rest time, the number of long or overnight shifts that are worked in a week, and so on.
Junior doctors did not like the banding system, but for different reasons. Payment for out-of-hours work constituted a large part of overall earnings, and so there could be significant variation in income between jobs. This could be a problem for doctors who wanted to purchase a house, for example, because they could not predict their future income even in the short term. It could also mean that a junior doctor who moved to a job with higher responsibility but a less intensive working pattern might take home less pay.
This variability and unpredictability in income added to financial pressures from increasing levels of student debt and the removal from most hospitals of free junior doctor accommodation. The costs of training and of being a doctor, including mandatory fees for professional registration with the General Medical Council (GMC), membership of a Royal College, examination fees, course fees, certificate of completion of training (CCT) fees and professional indemnity insurance, all rest with the individual junior doctor. The Doctors & Dentists Review Body (DDRB), which advises government on medical pay, noted that the basic salaries of doctors in training were in the lower quartile for their comparator professional groups.
Junior Doctors, whilst well paid at between £30k and £50k per year (including overtime), were beginning to look like members of a high-end ‘precariat’ – especially those with ambitions to work in the South East with its very high housing costs. We associate the idea of a ‘precariat’ with low-paid workers, but Seymour argues that “precarity is being thrust not just on migrants and the poorest, not just on women workers who become pregnant, not just on students and the young, not just on a shrinking manual workforce, but on public sector workers, from the bin men to the civil servants, from contract cleaners to health professionals”.iii
The NHS makes an offer
The New Deal contract had done its job of reducing the hours worked by junior doctors but was now considered obsolete by the Department of Health. Negotiations about a new contract for junior doctors began in 2012 and were interrupted by the BMA’s junior doctor negotiators in 2014, in protest at what they experienced as the government’s intransigence.
The principles – not the substantial terms – of the contract that Secretary of State for Health Jeremy Hunt proposed in 2015 included (amongst other things):
- The redefinition of normal working hours as 7am to 10pm on weekdays and Saturdays, with nights and Sunday attracting out-of-hours payments;
- An 11% increase in basic pay, with pay protection for those who might lose financially;
- An end to banding payments;
- An end to annual salary increments, with pay linked instead to stage of training;
- An upper limit to the numbers of hours worked, and to long shifts.
The response of the BMA junior doctor leadership to these principles was negative. Redefining ‘normal’ hours to include periods currently reimbursed as overtime would reduce income, although the 11% increase in basic pay would probably offset this for many. The end to banding was seen as a licence for NHS Trusts to exploit junior doctors and make them work more, not less, hours. Abolition of the salary increment was seen as an insult added to the injury of less overtime payment. Limiting hours of work further could lead to a further erosion of overtime pay, whilst shift length and other rules about breaks and rest periods are already in the existing contract or the European Working Time Directive.
Hunt threatened to impose a new contract based on these principles, in August 2016, unless negotiations re-started. This made the junior doctor ‘precariat’ take to the streets, threaten migration and predict an exodus into better-paid jobs outside the NHS. Five thousand junior doctors, medical students and supporters protested outside Parliament in September, and on October 17th 20,000 protested in London, in one of the biggest demonstrations that the NHS has knowniv. They saw Hunt’s proposals as a deliberate attempt to worsen their financial uncertainty. The BMA supporting its militant juniors, as did many (but not all) hospital consultants. An anonymous consultant summed up his experience as a junior doctor like this in the Health Service Journal:
“I am old enough to remember my 102 hour working week as a junior doctor and the burning resentment of earning 1/3 (yes not time and a third) of basic for every hours over basic (c 40 I think). I am an old lefty dedicated to the NHS and have never worked anywhere else – still working full time (about 60 hours a week including nights for 40 hours pay). But in my heart those years as a JD gave me a view of the NHS as a bloodsucking parasite that would take all it could from a doctor and throw away the husk when everything was gone. I was once told by medical staffing ‘there are plenty more where you came from’. I am right behind the junior doctors and so are very many of my generation’.
The employers in the NHS Trusts favoured the proposed principles, which would simplify out-of-hours payments and reduce their administrative and financial burdens, and privately thought the juniors were making a mountain out of a molehill.
It is difficult to know whether Secretary of State Hunt was deliberately promoting a fight, or had blundered into a conflict because he did not understand the undercurrents in the medical profession. He seemed unprepared for a dispute. For example, the economic modelling to show who would gain and who would lose from the new contract had not been completed, right up to the strike ballot.
Part 2: Strains in the NHS
From its beginning the public conflict with the Secretary of State for Health extended beyond the details of the contract, including making the NHS safer for patients and saving the NHS from the government. These new themes tapped into a deep resentment in the medical profession towards the management of the NHS by successive governments, from Blair’s second administration onwards. In 2005 the Modernising Medical Careers programme restructured medical training and increased the number of consultants by reducing the training hours needed to reach the consultant grade from 21,000 to 6,000. This was seen as positive because it accelerated promotion, but was disliked because it introduced a highly bureaucratic model of working in which doctors advanced in their career by gaining competencies based on a series of tick-box exercisesv.
To rationalise the appointment of junior doctor posts the Blair government tried, in 2007, to introduce an electronic system for matching applicants to training posts, the Medical Training Application Service (MTAS). The electronic system crashed almost immediately, and caused so much distress to junior doctors that they organised street demos and issued threats of emigration. The government retreated to fix the failed system, but the debacle revealed that 28,000 trainees – including applicants from the European Union – had applied for 22,000 jobs. With MTAS the prospect of substantial medical unemployment appeared for the first time in the NHS.
Then in 2012 the Coalition introduced a reform of NHS pensions, ending the final salary pensions that previously made NHS employment such an attraction for doctors. The BMA led a campaign of protests that rapidly petered out, leaving it looking both ineffective and overly privileged. One BMA Council member, Dr Kailash Chand, described the protest as the ‘wrong fight at the wrong time with the wrong tactics’.
In the same year the Coalition introduced the controversial and much challenged Health and Social Care Act that extended market mechanisms into the NHS, in order to reduce system stability and promote competition between NHS and private providers. The BMA opposed it, but ineffectively.
We can add to this list of stressors the government’s pressure to implement ‘7 day working’, and the stresses and strains produced by the short-fall in the health service budget between 2010 and 2015. The argument that the NHS should be functioning seven days a week not five became part of the Conservative General Election manifesto in 2015. The argument was based on evidence that mortality rates for patients admitted to hospitals is higher at weekends (now contested), that junior doctors felt clinically exposed and unsupported at weekends, and that hospital chief executives were worried about having enough medical staff, out of normal hours. It also seemed that the lack of many services at weekends had an adverse effect on measurable outcomes in each of the five NHS priorities: mortality amenable to healthcare, treatment of long term conditions, outcomes from acute episodes of care, patient experience, and patient safety. It also seemed inefficient that in many hospitals expensive diagnostic machines, laboratory equipment and pathology laboratories are underused, and operating theatres were unusedvi. Pressure was applied by the new government to make 7 day working normal for the NHS as a whole.
The NHS budget grows by 3-4% each year, above inflation, as new technologies and treatments are introduced and new staff recruited. The conservative government has restricted this increase to around 1%, which will result in a £22 million budget shortfall in the NHS by 2020. The growth in demand is so great that the hospital sector is struggling to solve the crises presented to it, whilst the NHS is now so constrained financially that its normal functioning cannot be guaranteed. The £22 million budget shortfall in England is too big to be corrected by increased productivity, new ways of working, pay restraint and reductions in expenditure on medication. The government’s expectation that squeezing the budget will stimulate higher productivity and creativity in work organisation is not shared by most of those running or working in the NHS. Their expectation is that staff will have to be sacked and services withdrawn.
Within a few years governments of different parties have demonstrated to new entrants to medicine that they face possible unemployment, but if successful will work hard in increasingly competitive and potentially unstable environments. At the end of their career they will receive a smaller (although still substantial) pension than their predecessors. The security and stability that the NHS used to offer to its medical staff, even when it was exploiting them, has been eroded. The rage of the junior doctors and their apparent determination to strike are understandable, given this background. Whether they were right about the new contract being a danger to their salaries or to patient safety was almost beside the point.
Much rode on this wave of anger. If the BMA failed to gain concessions from the Secretary of State, it would be damaged. Losing the argument about pensions and being over-ruled in the debates about the Health & Social Care Act have dented its image as the most powerful trades union in the country. Some in the health service would be secretly pleased if the BMA took a beating, because some doctors are seen as obstacles to change within the NHS. Angry juniors might decide to organise separately from the BMA, as they did in the run up to the 1975 dispute. If on the other hand the BMA could force Hunt to back down, his job would surely be under threat, especially if public perception continued to favour the junior doctors. The task he was given by the then Prime Minister David Cameron was to keep the NHS out of the headlines, and he was failing badly.
Part 3: The nature of medical work
In an average 8 hour shift a junior doctor can receive 100 new tasks, ranging from resuscitating someone in the A&E department to reviewing medication for a patient being discharged, or interpreting test results in an individual who the nurses think is deteriorating. Much of this work is ‘hands on – examining, ordering investigations, operating – but all the physical, tangible effort depends on immaterial labour, the use of judgement and discernment, openness of mind, the ability to draw on formal scientific knowledge and synthesis it with experiential knowledgevii. Training programmes for junior doctors are mechanisms for adding cognitive and social skills to the formal scientific knowledge acquired in medical school, so that tasks can be performed that require analytic expertise and collaborative working. The value added by this labour derives from the aptness of the web of communications woven around the productive process of medical care, as well the ability of individuals and teams to cope with the unexpected and to identify and resolve problemsviii.
A looser apprenticeship
Changes in the organisation of medical care in hospitals may have increased strain among junior doctors by undermining the ‘firm’ system of apprenticeship. The ‘firm’ was a hierarchical, collaborative work group of doctors of all stages of training, led by one or more consultants, which preceded the NHS and was taken over by it. Junior doctors belonged to firms which offered an apprenticeship style of learning that demanded long hours of work. The ‘firm’ system went into decline when the European Working Time Directive (EWTD) was enacted in the UK in 1998. Modernising Medical Careers (MMC) in 2005 further changed the training of doctors, favouring a looser organisation of shift-workers with less personal interaction to the tight but highly personal organisation of the ‘firm’ix.
So, under the old firm system junior doctors training in general surgery, vascular surgery or urology (bladder & prostate surgery) would work long hours in parallel teams. After the demise of the firm system these junior doctors would work shorter daytime hours but ‘out of hours’ (evenings and weekends) would provide cover across the three surgical specialisms. The consultants would work with a larger pool of junior doctors, determined by who was on shift. Junior doctors on night shifts during the week may not meet the consultants who are working during the day. Emergency cover may be provided by junior doctors who are not known to the consultant on call.
This immaterial work is demanding and stressful. The BMA began logging the stresses that junior doctors experienced, and its impact on them psychologically, before the contract dispute began. The union argued that the working patterns of junior doctors has turned training into a ‘trial of endurance’, identifying the ‘rapid, evolving change’ that the NHS experienced in 2011 and 2012 and poor job security for trainee doctors as causes of worsening mood and moralex. Adding insult to injury, bullying emerged as a widespread problem in the NHS. One study showed that a fifth of all medical students and a quarter of student nurses experienced or witnessed bullying in their first year of clinical training. Nurses resisted more than medical students, who acquiescedxi.
This experience is not confined to the NHS under Coalition or Conservative control. The same problems are documented in the very different health care system of the USA, most recently by Schwenk’s editorial in the Journal of the American Medical Associationxii. Doctors in training in the United States experience depressive symptoms at much higher levels than their peers in other jobs – ranging between 21% being symptomatic at any given point in their training and 43%. This symptom burden has significant consequences for doctors and patients, in terms of burnout, medical errors, ethical lapses and less personalised care.
Schwenk describes the working environment of doctors in training in terms that sound familiar in England, even if we would emphasise them differently: reimbursement systems for hospitals that limit the opportunities for patient engagement; life-prolonging technologies that lead to unsolvable ethical dilemmas; electronic medical records and documentation requirements that lead to inaccurate and sometimes dangerous cut-and-paste shortcuts; and short patient lengths of stay in hospital that require protocol-driven care with little opportunity for thinking and learning. Not to mention ‘consumer’ demand and fears about litigation. He sums up the problem like this:
‘The profession purportedly recognises the importance of health and wellness but the value system of the current training environment makes clear to residents (junior doctors) the unacceptability of staying at home when ill, of asking for coverage when a child or a parent is in need, and in expressing vulnerability in the face of overwhelming emotional and physical demands’.
Part 4: Strategy and tactics
The mandate for industrial action was huge but inevitably there were differences of opinion within the junior doctor workforce. The BMA organised two thirds of junior doctors, so there was from the outset scope for dissent from a sizeable group of doctors. Early on there were rumours of a division of opinion within the BMA itself about tactics, with a faction wanting to contain the combativeness of the junior doctors’ committee. The British Medical Association’s house magazine, the British Medical Journal, published a review of the dispute on December 5th 2015 that gave prominence to the views of Dr Henry Murphy, an Accident & Emergency trainee. He disassociated himself from the majority vote for industrial action and wrote about the ‘hounding’ of some of those who were opposed to strikes, calling for more respect for differences of opinion within the profession.
In the run-up to the first rounds of industrial action the dispute began to look like a classic ‘drawing-out’ battle, with each side is testing the other’s mettle, firepower, resources and resolve. The BMA and the government needed to know the same things. Would junior doctors actually strike in the numbers implied by the ballot? How many consultants would actively support them? How much collateral damage (patient harm) would there be? How would the media portray junior doctors, as champions of the NHS or as selfish and unprofessional? Could the government hold its nerve and sit out a series of strikes, and what room for manoeuvre would the BMA then have if it did?
The strikes between January, February, March and the beginning of April had an impact on the NHS, especially with the cancellation of outpatient clinics and some planned operations, but they were also symbolic. Junior doctors withdrew labour from 8am to 5pm, but the peak activity period for the NHS in terms of emergency admissions is from around 4pm to midnight, so striking doctors were still available for the busiest period for emergencies, after picketing outside their hospitals. The actual numbers involved in the strikes are unclear. NHS England reported that, during the two-day strike on April 6th & 7th some 12,800 junior doctors had been on strike, and 1,800 absent for other reasons (mainly sickness) xiii. This reliance on symbolic, short-term withdrawals of labour changed at the end of April.
The 48 hour walk out of junior doctors on March 9 and 10 2016 did not gain as much mainstream media coverage as the previous one day stoppages. Nor did it trigger government concessions on the new junior doctor contract. So in mid-March the BMA announced a full walkout by junior doctors, this time including those providing emergency care, at the end of April. Accident & Emergency department doctors were among those most concerned about the new contract and pressure for a full walkout had grown among BMA members frustrated that the union has so far proved powerless to prevent imposition of a new contract.
Junior Doctors’ leader Dr Malawana added: ‘We have shown solidarity, stated our case clearly and passionately to the public, and done everything possible to avert what could be the worst of all worlds for junior doctors – the refusal of the Government to get back around the table forces us down this road.’<
Public opinion polls show high levels of support for the junior doctors and social media carried testimonials from individuals expressing no anger, sometimes even gratitude, about their postponed hospital appointments. Yet there was also a sense that the dispute has gone on too long. Writing for the Guardian on March 13 2016, Sonia Sodha said:
‘So what’s the link between Saturday pay and patient safety? A BMA spokesperson told me the Saturday pay dispute will further damage junior doctor morale, with knock-on impacts for patient safety.Let’s call a spade a spadeThis is a workplace dispute about terms and conditions, not a campaign to save the NHS. There are bigger and more immediate risks to patient safety: hospital trusts under great financial strain struggling to meet safe nursing levels; cuts to social care budgets putting immense pressure on hospital beds.
This echoed a ‘plague on both your houses’ piece in The Economist on February 12 which sympathised with the junior doctors and criticised the Health Secretary Jeremy Hunt (whilst deeming him well intentioned). Unable to decide which side it favoured, The Economist blamed the British public for being an:
electorate that notionally adores the NHS, propels a mushy song by health workers to the top of the Christmas charts, happily accepts the left’s bogus insinuations that the only alternative is an American-style private health-care model, equally happily votes for Tory politicians promising to expand services to weekends and yet, despite all this, shows remarkably little willingness to pay more in tax towards what remains a relatively cheap system’.
Negotiation and bargaining
Profession and government did seem to be talking about different things, when they were talking at all. The message from NHS Employers’ was that agreement was close, the unresolved problem was about pay, but the BMA was inflexible and petulant. The BMA emphasised the gulf between the two sides, stressed that its interests in fairness and patient safety were noble ones, and complained that it was not taken seriously.
Whilst not taking The Economist too seriously, we might learn something useful from two particular economists, Roland Benabou and Jean Tirole, whose 2009 essay ‘Over My Dead Body: bargaining and the price of dignity’ casts some light on the disputexiv. They say:
‘Concerns of pride, dignity, and the desire to ‘keep hope’ about future options often lead individuals and groups to walk away from reasonable offers, try to shift blame for failure onto others or take refuge in political utopias. Costly impasses and conflicts result’.
Both sides blamed the other, and the junior doctors – many of whom genuinely believed they were saving the NHS –were offered a political dystopia. As the junior doctors’ leader Dr Malawana put it, failure to achieve the BMAs objectives would bring about ‘the worst of all possible worlds’, which seems an odd conclusion after months of negotiation had apparently brought both parties closer to a resolution. Nor was it made clear how an uplift in basic pay but a reduction in Saturday overtime pay might constitute the worst of all possible worlds?
Andy Cowper, writing in the BMJ in February 2016, argued that concessions obtained from the government could have been presented as success, had the junior doctors’ leadership been less entrenched and politically and strategically smarter. And, he added, both Hunt and the junior doctors leaders might have been enjoying the ‘power trip’xv.
The withdrawal of all labour for two days at the end of April 2016 had an effect on both the performance of the NHS and the nerve of the BMA, and negotiations restarted, with help from ACAS. The contract that emerged from these negotiations was accepted by the BMA leadership but rejected by their membership, although with a reduced turn-out and only a 3:2 majority against acceptance. Whilst plans for 5 day walk-outs, including emergency care, were being made, the BMA surveyed its junior doctor members about the wider range of problems beyond the contract, and started to hear concerns about the disproportionate tactics being proposed. Leaks from within the BMA to the Daily Mail suggested there was widespread opposition to the planned 5-day strikes amongst junior doctors. The BMA survey results were not published.
Capitulation, when it came, was complete. The strike planned for early September 2016 was the first to be abandoned. On Saturday September 24 the BMA announced a suspension of all further junior doctor industrial action in England. This followed feedback from doctors, patients and the public, and discussions with NHS England about the ability of the NHS to maintain a safe service if the industrial action planned for October, November and December were to go ahead.
The defeat was ignominious, and made worse by a failed legal challenge to the Secretary of State’s right to impose a contract. Senior members of the medical Royal Colleges, who had tried to walk a fine line between supporting junior doctors and ensuring the health service could function, began to speak(off the record) about ‘Generation Me’ – entitled young people who want lots of money but not to work hard, and feel they should have it all. Hospital managers who noticed how much more efficient their services were when consultants delivered them are wondering if having so many junior doctors is the best option for the NHS.
Only one of the three disputes has been settled, with a new contract that is being introduced despite being rejected by many thousands of junior doctors. Important concessions were obtained from the government, but no doubt loopholes will need to be closed and snags removed. Local, hospital level, bargaining will help tailor the new contract to circumstances, and local vigilance by the BMA should counter attempts to increase junior doctors’ hours. Overall, the government achieved its desired re-categorisation of Saturday working as normal working hours, taking it a step closer to 7 day working. It seems unlikely that there will be any further national dispute over junior doctors’ working hours in the near future.
The pressures inside the NHS are building up, as cash-flow crises are averted just in time, and managers struggle to streamline services or just keep up with demand. This is a political dispute that may well overshadow the 2020 general election, but it is not amenable to industrial action within the health service by a section of one profession, and its outcome was never in the junior doctors’ gift. At first sight it seems was remarkable that they thought it was. This identification of the needs of some doctors with the needs of the NHS as a whole, and of the public it serves, exemplifies LeGrand’s analysis of medical professionalism as a game of Knights and Knavesxvi. In Knight mode the profession draws attention to its altruism, its central concern with the patient, and its willingness to go beyond the usual limits (including overtime working) to help others. In Knave mode it points out that its altruism will not be sustainable without more income. Much of the confusion in the junior doctors’ dispute arose from this dualism.
Debates on NHS funding will dominate politics up to 2020, but the other problems revealed by the junior doctors’ dispute will not go away, and there are many questions left unanswered. The tensions inherent in modern medicine are the province of the medical and surgical Royal Colleges, whose brief it is to define and nurture professionalism. At the very least systems of mentoring and support for doctors in training need to be invigorated and applied. There may also be a case for a wider debate about the effects of immaterial labour on medical, nursing and allied health professional workforces, all of which have problems of recruitment and retention of staff, and how to ameliorate them.
Do we have in the NHS a high-end precariat, becoming used to less secure employment than their predecessors? If yes, will this be a problem that a future Labour government could solve? Stabilising the medical labour market, perhaps even restoring the old firm system, might be possible, at a price. The price will need discussion, for trading off shorter working hours for less income security may become acceptable to doctors who are, after all, on their way to affluence. Should a profession earning in the top 10% of the income distribution enjoy the security earned by the generations that founded the NHS, in a society where growing inequality is so salient?
Finally, there is the BMA, defeated repeatedly by successive governments but now readying itself for contract negotiations for hospital consultants and general practitioners. It was intoxicated by the energy of the junior doctors, only half grasping the impossibility of their aims. Will it recover its power?
Acknowledgements: I am grateful to all the senior and junior doctors who shared their ideas, impressions and understandings of the junior doctors’ dispute with me. The interpretations in this review of the dispute are entirely my own.
Steve Iliffe, December 2016
Steve Iliffe took part in the 1975 junior doctors’ industrial action in 1975 as a House Officer at Leicester Royal Infirmary, and was co-author of the history of the dispute, ‘Pickets in White’, published by the Medical Practitioners Union in 1977. He is emeritus Professor of Primary Care for Older People at University College London.
i Gordon H, Iliffe S Pickets in White: a study of a profession in transition Medical Practitioners Union, London 2007
ii Holborow A Why are juniors so keen to cling to banding? BMJ 19th March 2016
iii Seymour R We are all Precarious – on the concept of the ‘Precariat’ and its misuses. New Left Project 2012 http://www.newleftproject.org/index.php/site/article_comments/we_are_all_precarious_on_the_concept_of_the_precariat_and_its_misuses (accessed 12/9/106)
iv Meghi S, Rajan N, Philpott J What does the junior doctor contract mean for me, my patients and the NHS? J. Royal Soc Med 2015; 108:470-472
v Beale R On course for disaster London Review of Books, 10th December 2015.
vi NHS Services, Seven Days a Week Forum : Summary of Initial Findings First published: December 2013, NHS England
vii Gorz A The Immaterial Seagull Publishers, London 2010 p5
viii ibidem p8
ix Timm A The demise of the firm – What is happening to apprenticeship learning? Medical Education Development Unit , Faculty of Medicine, University of Southampton February 2013
x Health Policy & Economic Research Unit. Cohort study of 2006 medical graduates: 7th report. BMA, April 2013.
xi Timm A. ‘It would not be tolerated in any other profession except medicine’: survey reporting on undergraduates’ exposure to bullying and harassment in their first placement year. BMJ Open. 2014 Jul 9;4(7):e005140. doi: 10.1136/bmjopen-2014-005140.
xii Schwenk TL Resident depression: the tip of a graduate medical education iceberg JAMA 2015; 314 (22): 2357-8
xiii www.england.nhs.uk/2016/04/update-junior-doctors-4/ (accessed 15/10/16)
xiv Benabou R, Tirole J Over my dead body: bargaining and the price of dignity Am. Economic Review: papers and proceedings 2009;99:459-465
xv Cowper A Megaphone diplomacy fails BMJ 20th February 2016
xvi LeGrand J Motivation, Agency & Public Policy: of knights and knaves, pawns and queens Oxford University Press 2003.
Health service politics doesn’t generate much laughter, despite the gallows humour that swirls round hospitals and health centres. This is changing, as a look at NHS Networks will show. Its latest offering is ‘Build your own Forward View’, which it explains like this: Now you can build your own forward view in just 260 fun-to-collect parts.
Build Your Own Forward View is from the same people who brought you Become a World Class Commissioner in 5000 Easy Steps and NHS Reform for Dummies. Every fortnight a new part will be published on the NHS England website. Once you’ve collected all 260 you’ll be able to construct an impressive scale model of what the NHS might look like in future, complete with realistic details such as streamlined hospitals that don’t require propping up with extra cash, patients who rarely become ill and a social care system that hasn’t imploded.
But remember, this is not a plan, which means it doesn’t come with instructions and is not guaranteed to work. That’s what makes it such fun!
The Build-your-own-forward-view kit will include a cliché generator, and some self-assembly new care models which come with a small tube of glue. Purchasers are encouraged to order doctor and nurse figures soon because supplies cannot be guaranteed. The first issue is out now, and costs only £10 billion.
Other irresponsible goodies available at NHS Networks are ‘NHS England denies plan to cull older people’, ‘Home surgery could spell end of NHS cuts’ and ‘Andrew Landsley: a blithering case study’.
A matter of words?
Labour’s day of action for the NHS on November 26th was low key, and in balance this was rightly so. The news filtered through to members only a few days before the leafleting began, so party mobilisation was less than it could have been. On the positive side the tone of Labour’s language was measured. Instead of saying that the NHS was on its knees, or close to collapse, or in meltdown, it argued that more funding was needed for social care, and that important targets were being missed because of under-investment in the health service itself. The contrast with the materials of the more macho “Fightback” day of action on December 3rd was clear.
The Conservatives are in a good position with the NHS. Their Secretary of State for Health has defeated the BMA in the junior doctors’ dispute, demonstrated that holding your ground works, and exposed the amateurishness of the medical profession’s union. May’s government seems to be working on the assumption that Labour’s campaigning on the NHS is not increasing support outside its core vote. As Owen Jones put it in the Guardian December 1st “Labour would save the NHS, but the NHS won’t save Labour”.
After six years of austerity public concern does not match campaigners’ (and professional lobbyists’) sense of “crisis”, mostly because the NHS is working well in lots of ways and places. Nonetheless there is enough steam behind the catastrophising to taint all local plans for change with the belief that their only intention is to cut services.
Crying wolf in a situation where the health service is still mostly providing good quality care undermines the credibility of campaigners wanting to ‘save’ the NHS and professional interests within the health service seeking more funding. The government will take advantage of this by questioning the judgement of campaigners and the competence of those providing and managing the service.
Alistair McClellan, editor of the Health Service Journal, describes this situation bluntly. “The NHS now faces a hard choice. It can indulge in a crescendo of virtue signalling, with various interests attempting to outdo each other in depictions of impending doom, the size of investment needed to deal with it and/or the number of celebrity endorsements. This is unlikely to work.” So what will work? Labour needs to know if it is to inform and engage its members inside and outside the NHS.
Williams and Innes Pearse developed a new approach to primary care in the 1930s which attained its apotheosis with the development of the Peckham Pioneer Health Centre. This relegated traditional healthcare to a subsidiary function in relation to what today we would call the wellbeing functions such as various physical activities, leisure pursuits, education and social interaction. Patient nutrition was seen as a key component of promoting health.
Paradoxically the project was undermined by the introduction of the NHS with its emphasis on the delivery of medical technology by general practitioners and hospital consultants.
The time has come to reinvent Peckham and to develop it further by transforming primary healthcare from a mainly reactive entity to a determinedly proactive one and by broadening its purview from the individual and the family to the local community.
Without affirmative action to identify the healthcare deprived in order to provide appropriate high quality healthcare NHS primary care will continue to increase health inequalities because the health advantaged currently get more out of it than the health disadvantaged. At individual GP level it should be possible to identify healthcare deprived patients from the Practice Register and then contact them to ensure that they take advantage of the services they need. This is outreach at the individual patient/family level
Generally speaking public health has been delivered from on high, from central, regional or district level and has signally failed to engage with real people in real communities.
There is a growing realisation that local communities must play their part in promoting the health and wellbeing agenda; and that a key vehicle for this is community development.
Two convenient platforms for delivering community health and wellbeing are general practice and the local secondary school acting as a community school or college.
A model the author envisaged some years ago based in part on his experience as a Councillor for a deprived ward in a large provincial City involved General Practice premises/Health Centres providing in addition to the traditional primary healthcare a range of wellbeing services such as Benefits Advice and social services; and fulfilling a signpost function in respect of other wellbeing services such as housing advice and environmental health.
The other limb of this community health and wellbeing axis would be the local secondary school acting as a community school or college supplying education and lifelong learning opportunities as well as sports facilities and opportunities for social activities of various sorts.
Public health leadership would be provided either by a suitably trained General Practitioner, or more likely, by a health visitor or health promoter working within the primary care team and relating to the local community and and its key institutions.
The nearest approach to this model that I am aware of is the Bromley by Bow Health Centre in East London.
Knowing what we now do about the determinants of disease and the promotion of wellbeiing and if we are serious about reducing inequalities in health moving from the traditional reactive primary healthcare model to a new proactive community health and wellbeing framework is the way forward.
Paul Walker. December 2016
Leading European insurance companies are now helping their clients to reduce health risks with new Digital Health based services. Wellmo is emerging as a leading player in these flexible solutions. Wellmo’s customers have a combined base of 7 million clients. In the near future, the preventive digital health service market will be worth several billion euros in Europe, according to Jaakko Olkkonen, the Managing Director of Wellmo.
In Germany alone the total healthcare expenditure is over 300 billion euros. According to the OECD, the expenditure in the Euro area is over €1000 billion. The majority of those funds go through either public or private health insurance. For instance in Germany, only 3 percent of this amount is used for preventative services.
There is evidence that digitally assisted lifestyle modification programmes connected to sensors and remote coaching are helping consumers to pay attention to healthy living, reducing their risks for chronic diseases. Highly personalized and cost efficient mobile services are helping people take charge of their own health, live healthier lives, and reach their goals. Leading insurance companies have started to redefine insurance business with the help of these digital services. In addition to traditional financial cover, insurers have started to offer their members lifestyle coaching programmes and rewards to help them manage their risks better.
A good example of Wellmo-powered new approach is Local Tapiola’s Smart Life Insurance concept. It was launched a year ago, combining financial cover with virtual health check and coaching, tracking of individual’s own activity and sleep quality, as well as a mobile app to collect wellness data and to integrate all services included. A survey of the participants reveals that Smart Life Insurance has helped to effect a positive lifestyle change: over 80% of the participants say they have improved their lifestyle, with 88% reporting improved habits now being a part of their daily routines.
Over 20 international clients
With its background with Nokia, Wellmo has developed a market leading mobile health solution that enables insurance companies, as well as advanced health service providers to offer rich branded digital health services. During the past three months alone, Wellmo has gained four major insurance companies as customers and entered new insurance markets in Germany and Benelux.
Together with its customers and partners, Wellmo is building a compatible and adaptive ecosystem. Wellmo’s role is to facilitate the creation of a uniform mobile user experience and data exchange between the various partners, while ensuring regulatory compliance. The ecosystem is open and grows continuously. It currently includes partners for wearable devices (e.g. Garmin), coaching services (e.g. Trainer4You, Pim Mulier, Fysergo), health & wellness content providers (e.g. Duodecim), lifestyle intervention platforms (e.g. MealLogger), and communication technology providers (e.g. Netmedi).
For more information, see: www.wellmo.com
The Royal Society for Public Health (RSPH) has welcomed a major new evidence review on the health impacts of alcohol, published by Public Health England (PHE) on 2nd December 2016). RSPH believes the findings should provide fresh impetus for the Government to take firm action to tackle alcohol harm, including the introduction of Minimum Unit Pricing (MUP).
The latest review indicates that 10 million people in England are drinking at levels that may be damaging to their health. It also confirms that alcohol is now the leading risk factor for ill health, early mortality and disability among 15-49 year olds.
The review assesses the effectiveness of policies for reducing alcohol harm, and finds policies that reduce the exposure of children to alcohol advertising, and which tackle the availability of cheap alcohol through taxation and price regulation, such as MUP, have the greatest potential. MUP is already on its way to implementation in Scotland following a successful legal review.
Shirley Cramer CBE, Chief Executive RSPH said: “The health harms of alcohol affect all sectors of society, but are felt most by the poorest and most vulnerable. All the evidence now points to MUP as one of the most effective potential ways to tackle these inequalities in harm. We are hopeful that this mounting evidence will be taken on board by Government.
Advertising is another key area where action is required. The more our children are exposed to alcohol advertising, the more likely they are to drink frequently and in greater quantities, harming their health and life chances from an early age. If the Government is serious about protecting the health of our children, it must take on board the evidence and act to regulate in this area.”
In the early years of the coalition government, David Cameron lauded the measurement of happiness and well-being as an indicator of national performance, the happy index. Data on life satisfaction have been collected and publishedby the Office for National Statistics every year since 2012. Despite this, very little is said about well-being. It is not discussed at spending or policy reviews and rarely in the media. Gross domestic product (GDP) continues to dominate the coverage of national performance and the potential impact of policies such as Brexit. Nevertheless, a precursory glance at the data can reveal an interesting picture of national well-being.
The map above plots the proportion of people reporting their life satisfaction to be ‘high’ or ‘very high’ across England and Wales. This corresponds to a score of seven or more on a ten point scale in response to the question:
Overall, how satisfied are you with your life nowadays? Where 0 is ‘not at all satisfied’ and 10 is ‘completely satisfied’.
There are clearly variations across the country, with the most obvious being the urban/rural divide. The proportion of people reporting ‘high’ or ‘very high’ life satisfaction in the UK has also increased over time, from 76.1% to 81.2% between 2012/3 and 2015/6, corresponding to a mean life satisfaction rating rising from 7.42 to 7.65.
Well-being data can also be used to evaluate the impact of policies or interventions in a cost-benefit analysis. Typically an in-depth analysis may model the impact of a policy on household incomes. But, these changes in income are only valuable insofar as they are instrumental for changes in well-being or welfare. Hence the attraction of well-being data. To derive a monetary valuation of a change in life satisfaction economists consider either compensating surplus or equivalent surplus. The former is the amount of money that someone would need to pay or receive to return them to their initial welfare position following a change in life satisfaction; the latter is the amount they would need to move them to their subsequent welfare position in the absence of a change. For example, to estimate the compensating surplus for a change in life satisfaction, one could estimate the effect of an exogenous change in income on life satisfaction. Such an exogenous change could be a lottery win, which is exactly the approach used in this report valuing the benefits of cultural and sports events like the Olympics.
Health economists have been one of the pioneering groups in the development and valuation of measures of non-monetary benefits. The quality-adjusted life year (QALY) being a prime example. However, a common criticism of these measures is that they only capture health related quality of life, and are fairly insensitive to changes in other areas of well-being. As a result there have been a growing number of broader measures of well-being, such as WEMWBS, that can be used as well as the generic life satisfaction measures discussed above. Broader measures may be able to capture some of the effects of health care policies that QALYs do not. For example, centralisation of healthcare services increases travel time and time away from home for many relatives and carers; reduced staff to patient ratios and consultation time can impact on process of care and staff-patient relationships; or, other barriers to care, such as language difficulties, may cause distress and dissatisfaction.
There are clearly good arguments for the use of broad life satisfaction and well-being instruments and sound methods to value them. One of the major barriers to their adoption is a lack of good data. The other barrier is likely to be the political willingness to accept them as measures of national performance and policy impact.