NHS III - this time it's another post about the NHS

Why do we need to modernise? According to the Prime Minister, the NHS is "second best". The Government's white paper states that they aim to 'once again make the NHS the envy of the world' and 'success will be measured, not through bureaucratic process targets, but against results that really matter to patients ' It is very difficult to find recent data, but given that the last World Health Organisation (WHO) report comparing data was 2007, well into the New Labour government it seems reasonable to use it. I have also used data from Organisation for Economic Co-operation and Development reports (OECD), which also only provide data up to 2007. So, given these provisos, how second rate is the NHS? 

In 2007, WHO* ranked the UK as having the 18th best health care in the world. Top was France, and second was Italy. Also above the UK were a number of small countries such as Andorra, Malta, Singapore and Oman, which don't really bear much comparison. 18th place was achieved at a cost of 8.2% of Britain's GDP. This was the 41st highest amount and compared to France's 11.2% and Italy's 8.9%. All of the developed countries that were higher in the league spent a far larger percentage on health than the UK, with the exception of Japan and Spain, who spent the same as the UK. Notably, the UK performed much better than many developed countries with much higher spending. Switzerland's 11.4% got it 20th place, Germany's 10.7% brought in at 25th place and most  damning of all, The USA's 15.2% got it placed 37th, just behind Costa Rica and Dominica. 

If we look at the expenditure on health per head of the population the NHS again comes out of the stats very well. Britain, spent $2990, the 18th highest amount, on health per person. Top placed France spent $3593, 20% more,  German (25th) $3619, 21% more, Switzerland (20th) spent $4469, 95% more and the USA (37th) spent $7285, an astonishing 144% more. Once again Spain (7th) out performed the NHS with expenditure of $2658 per person, 12% lower and Italy $2701 (2nd) also had a 10% lower. However, if we take into account the cost of living in each country, according to the OECD stats, it would make Spain the same as the NHS and Italy more expensive. All of the other countries would remain relatively more expensive than the NHS for a worse ranking. 

So what about outcomes? Once again it is difficult to get good data. The last OECD report  on what are known as 'preventable deaths' was 2004. In the developed world, these are the sort of thing that are often associated with risk-taking such as smoking, drug abuse and daring to cross a road. I suppose there is a strong cultural quality to this indicator but I would argue it demonstrates how well the broader aspects of health care, such as education, are working. In 2004 we were in 12th place. Once again the USA was lagging behind and so was Austria, who the Prime Minister has been held up as a shining example of good practice recently. We also beat the WHO's top ranked country, France. No country, spending less per head, when cost of living is taken into account, had a better ranking. 

The Coalition have said that there will be 'a relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients – such as improving cancer and stroke survival rates.' In 2009 some alarming statistics from an OECD report were widely reported in the British press. 'The sick man of Europe' - said The Telegraph, who stated that, 'heart and cancer survival rates were amongst the worst in the developed word.' A WHO bulletin, published soon afterwards, argued that these results were an example of 'non-transparent framing' which was explained as data provided as a 'deliberate tactic to manipulate or persuade people.' 

These are the same stats that the Coalition have been throwing around to prove that the NHS is 'second best'. It certainly sheds a new light upon the white paper when it says, 'Patients will have access to the information they want, to make choices about their care'. In the bulletin, Gerd Gigerenzer. an expert in 'risk literacy' from the Max Planck Institute in Berlin examined the apparent chasm between UK (35%) and US (60%) survival rates of 5 years after being diagnosed with colon cancer. In fact as, Gigerenzer demonstrates, the mortality rate is 'roughly' the same. The difference in so called 'survival rates' is actually largely explained by the widespread screening in the US which leads to massive over diagnosis of non-progressive cancers. For those categories reported by the press, the UK was placed 12th overall, once again ahead of the curve in relation to our relative funding.

The Coalition continue to stress that Britain is not getting the appropriate results in return for the increased spending over the last thirteen years. After years of under-investment there has been a massive increase in spending, from 6.6% to 8.8% of GDP, which the government has repeatedly told us is in line with the EC average. That might be the case, but if we compare spending with the older, more developed EC members or those from Scandinavia, from my reading of the information, Britain still spends less (%) than all the other countries. According to the OECD, even Spain overtook us in 2008. 

Is the NHS 'second best'? Well, it probably is. But, I hope, that this post has demonstrated that it is more to do with continued under-funding rather than with the structures or productivity of the staff. Even with the limitations of the data it seems safe to conclude that we are getting excellent value for money from the NHS. The dedicated staff punches above its weight across a range of indicators. These are staff who  regularly put in that little bit more because they feel valued by their employers and the community and recognise that health is more than a job. These are the staff who will shortly be sold down the river in exchange for higher share dividends. 

Philosopher George Santayana defined fanaticism as "redoubling your effort when you have forgotten your goal." It seems apt, in these circumstances because if there is one firm conclusion I can draw from my reading; it is that the involvement of the private sector does not guarantee any great leaps in productivity or quality of outcomes. As we have seen over the last couple of years, the private sector is not even that good at making money. Outcomes are obviously important but the NHS is important for other reasons. It is a glue that binds our society and can't be measured in perecentage points. Sadly, the Tories are too blind to see that these rather intangible qualities mean that the NHS is still the envy of the world. 

So how to modernise? Well, if we want to knock France off the top of that league - we'll have to spend a lot more money, but I suspect, not as much as France. 

*WHO’s assessment system was based on five indicators: overall level of population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); and the distribution of the health system’s financial burden within the population (who pays the costs).

NHS Reform II - the 'disordering' of society

A few weeks ago, a GP friend told me he had been contacted by an undergraduate with 'Executive Function Disorder'. The condition had been diagnosed by educational psychologists after he failed his exams. The 'disorder' presents the sufferer with difficulties in: 'organising, prioritising and activating work'. In my day that would have applied to virtually every student I knew. The student, having been given short shrift by his current GP, had contacted the practice to see if they would treat the condition. I was reminded of this story when I was reading the Government's 'white paper.'

According to the proposals, the Coalition's ambition is to 'liberate' the NHS. From what it is being liberated, they don't make clear:  

'First, patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care. Second, there will be a relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients – such as improving cancer and stroke survival rates. Third, we will empower health professionals. Doctors and nurses must to be able to use their professional judgement about what is right for patients. We will support this by giving front- line staff more control. Health care will be run from the bottom up, with ownership and decision-making in the hands of professionals and patients.'  

As anyone who has ever stayed in a Disneyland resort will tell you, even the most 'magical' places can treat visitors like cattle. Massive institutions are essentially dehumanising because they have to process such large numbers and individuals can often get lost in over all outcomes. There is no doubt that requiring treatment within the NHS can sometimes leave you feeling slightly soiled. I'm sure you have had good and bad experiences. I'm not entirely sure what putting 'patients at the heart of everything' actually means, but, if it were to insist that everyone is always treated with appropriate dignity then that is a worthy aim. 

By calling them 'second rate', paying them less and removing decent working conditions, I don't think the staff are being treated with much dignity. Anyone who has worked in health care will know that the system has always worked through the 'good will' of many practitioners filling the gaps between their jobs and the work actually required. This is the 'vocational' aspect of the job. Turning the work into a contractual agreement has always missed this point. One of the shocks for the Labour Government, following the now infamous GP contract, was that they ended up paying for things that GPs had largely always done because they were good practice, not because they were paid. Despite what you may think, health professionals are still working over and above what their contracts state. Let's see the private sector bring that attitude to the table. 

Unfortunately, what the government means is 'no decision about me, without me.' The Coalition are selling us a wonderful vision: choice about what treatment, carried out by which top professional, where and when? All of this, of course, will be based upon freely available information with which to make a fully informed judgement. It sounds amazing, but, as 'JPD' commented on the blog yesterday, 

"I don't want a choice about where I have my kidney stones out! I just want decent treatment locally. I have enough stuff to worry about without trying to work out whether the decreased relative risk of dying is worth the higher cab fare."

We will all be affected one way or another. What about the families of the one in five of us who, it is now projected, will reach 100. Will they want anything but effective local services for the aging relatives? Anyone who has spent time researching a new TV purchase on the internet will immediately shy away from the thought of making like for like judgements on something as vague as medical outcomes. As one orthopaedic surgeon I know has pointed out: in a free market, driven by profit and with patients making judgements based on historical outcomes, no one will take on the difficult cases anymore. Why would hospitals or individual practitioners risk having their averages damaged? 

According to the Government 'patients will be in charge of making decisions about their care.' My friend, the surgeon, spent six years in medical school in London, another 14 years getting all his surgical examinations and also has a number of years experience on top of that as a consultant...and the patient is in charge? Perhaps they are big fans of casualty? As patients, we are already 'in-charge', as much as we can be. We say 'yes' or 'no', but there is a big gap between that and most patients being able to make truly informed decisions about treatment. The proposals insist that 'Doctors and nurses must to be able to use their professional judgement about what is right for patients' but one of the great myths that recent politicians have peddled and, I think is rife within society these days, is that everyone's opinion is equally valid. Everyone has a right to express their opinion, yes, but that is not the same thing at all. I don't want a hospital consultation that takes the form of a Radio 5 phone-in. Let's regulate the health professions in a thorough and credible way and then back their clinical decision-making. 

The response to the student was to tell him that 'Executive Function Disorder' is not an illness. They have drawn a line and said, "sorry, there may be something wrong with you but it is not a health issue." Perhaps we should back health professionals to do that more often. The 'disorder-ing' of our lives has reached epidemic proportions.  Forty years ago Woody Allen joked that, " I don't want to become immortal through my work, I want to become immortal by not dying." Unfortunately, I think many people no longer see this as an unrealistic expectation. Too often the punchline on Woman's Hour - don't tell the lads please - is 'if you are not sure, speak to your doctor.' It's as if the GP has become the secular world's  father / confessor. Is there any wonder the NHS is feeling the pressure.

Anyway, I must stop, the Mrs wants to have a chat about my 'Cricket on TV lethargy syndrome'. Amen.

Is this the end of the NHS?

The NHS came into existence on 5th July 1948. It had three founding principles: that it meet the needs of everyone, that it be free at the point of delivery and that it be based on clinical need, not ability to pay. The Coalition's health reforms essentially represent the end of this NHS. It seems that the main aim of the Health Secretary, Mr Lansley, is to hand over the provision of NHS care to private companies. This policy is called “ patient choice. ” Although, the result will be less choice. The new GP Commissioning Consortia will control 80% of the commissioning budget but they will immediately need to cut one fifth of the NHS budget (£20 billion). It also looks as if the GPCCs will take on the debts of the Primary Care Trusts (PCTs), which are being abolished. The inevitable removal of services, because of the cuts, will therefore be blamed on the GPs and not the government.

In effect, GPs have been given no choice but to form consortia (GPCC) which will have the job of commissioning NHS care under the control of a National Commissioning Board (NCB ). The lack of business expertise and commissioning experience means that GPs, inevitably are turning to private health organisations, our local consortia already has close links to one of these companies. As I pointed out in a post last week there is serious and possibly damaging conflict of interests when GPs become both the service providers and service purchasers. This situation will be exacerbated by the need for cuts but also the demands of the new market regulations and the instruction to reduce the level of GP referrals to hospital.


The NHS will no longer be the 'preferred provider' of services. All services will be open to 'market' competition. This sounds like a sensible practice until you realise that that will mean the closure of local hospitals and services. Local hospitals will have to 'make' money or else go out of business. As in all developed areas of private enterprise, the market will create larger, more powerful corporations not more choice for the consumer or patient as some people still insist on calling them. Decisions will be profit rather clinically driven.

The winners will be the shareholders of the powerful private firms standing by to take a share of the budget. Patients and NHS employees will lose out to pay shareholder dividends. Like a new supermarket selling 'loss-leaders' these firms are powerful enough to drive NHS providers out of business in order to dominate the market. The losers will be the patients who will have to travel further for treatment and, almost inevitably will see the 'free' services rationed. As one GP commented to the BBC, "That’s a chilling prospect for the elderly, those with chronic illness and people with mental illness and long-term needs, who are often of no commercial interest to the corporate providers because of their high health care costs."


The other losers, of course are  the NHS staff. They will see thousands of jobs cut and many will be forcibly transferred to the employment to private companies with removal of national terms and conditions and NHS pensions. Why should you care about the 'second rate' health care professionals, to use Cameron's words? All I would say is: did hospitals get cleaner or dirtier when the cleaning contracts were transferred to the private sector? Will paying people less improve the quality of care? Will it encourage the next generation of bright and talented young people to work in health care?


The proposals have even brought criticism from within the Conservative Party. Notably, Stephen Dorrell, the former Tory health secretary and chair of the all-party Commons health select committee, gave a damning response. In the committee's report he stated, that the reforms would create 'significant institutional upheaval' and although 'We share the government's objectives. We also say that this is in several respects not the most effective way to deliver them." Like the rest of us the committee was very surprised that none of these proposals were mentioned during the election campaign. The plans were denounced on Monday by six health service unions - including the British Medical Association and the Royal College of Nursing - as "potentially disastrous".


The point is that for many people, wealthy enough and educated enough, these reforms may not have much of an impact. As usual, it will be the poorer sections of our society who will be most disadvantaged. Is that progress? (Cue Elgar - this is the Oscar winning scene) Perhaps it is sentimental on my part, but those founding principles, the interpretation of which may be at the heart of the NHS's problems, have always struck me as something that was truly inspiring and thoroughly democratic at the heart of our culture. I really think that it sets us apart. The NHS is imperfect, so reform, yes, but, let's not throw those aspirations away.

Shall I be mother?

The current rules about parental leave "patronise women and marginalise men". That is the view of, father of three, Nick Clegg, who has announced proposals to allow couples to share paternity leave. Fathers will be able to take up any remaining unpaid leave if their partners return to work without using their full entitlement. Clegg has criticised the rules as 'Edwardian' and has confirmed that the Coalition intend to consult on a complete reform of  parental leave by 2015. 

According to the BBC, the proposals will also allow parents use the leave entitlement together and to take leave in separate periods rather than as one continuous period. The reforms were first announced by Labour last January and their proposals seem to have found support with right-wing think-tank Demos. Their report concluded that: 'Rather than pay, the keys to maintaining parents' confidence in their ability to bring up children were flexible hours and the ability to be creative at work.' 

The Coalition want to create a more flexible system that will make the leave work for families' individual needs. The report entitled The Home Front, concludes that being in employment is good for parenting but can have a negative impact when the job is characterised by inflexibility in terms of hours and the culture of the workplace. The report also highlights that fathers work longer hours than childless colleagues, with a third putting in more than 48 hours a week. In 2010 the Department of Work and Pensions reported that 76% of mothers return to work within 12 to 18 months of having a child. It suggests that parents either don't enjoy childcare that much or that money, contrary to the Demos report, is a major consideration in deciding on childcare priorities. 

Jill Kirby, a director of the Centre for Policy Studies and author of 'The Price of Parenthood' says that:

"around 50,000 stay-at-home mums have been forced back to work over the past year. Faced with high mortgages and rising household costs, the number of stay-at-home mothers has dropped to just 2.07 million, the lowest level since records began in 1994. The overwhelming reason for mothers to return to work is sheer financial pressure, often much earlier than they would like. Many women do feel really trapped by their own situations."

A recent study by uSwitch.com found that average family income drops 34% during maternity leave, one in four mums end in debt, with an average of £1329 and 50% of mothers returning to work, with children under three, said the reason was financial presure. A YouGov Poll in 2009 found that a third of working mothers would not work at all if they had a choice. 

In the same year a report, 'What women want and how to get it' produced by the Centre for Policy Studies written by journalist Cristina Odone argued that 'notions of women's progress over the past decade have been measured by the 'wrong' things, such as more women in top jobs, a shrinking earnings gap and better state-funded childcare...There also needs to be a cultural shift where women are valued "not just for what they produce at the end of a working day.'

The slack in childcare has been taken up by day-nurseries. There are now 15,000 nurseries in the UK and around 277,000 children under three are enrolled in day nurseries, and 21% of children aged under two spend some time in day nurseries. After grandparents, day nurseries are the most popular form of childcare for working parents who have children under three. 

As Cristona Odone concluded, what parents really want is the choice. Her report recommended that rather than simply offering childcare vouchers; families should be able to get national insurance credits for carers, allow working partners to take up the unused tax allowance of the other parent and make it easier for firms to employ part-time workers.

Meanwhile, in Brussels back in October, the 'family friendly' Coalition MEPs voted against draft legislation that would entitle mothers to 20 weeks maternity leave on full pay. The current entitlement in Britain is six weeks. The Coalition is strongly opposed to the legislation because of the possible effect on British business and is lobbying the Council of Ministers who will have the final say. What I think is truly patronising is the belief that a cheap 'family friendly' makeover will hide where the Coalition's true priorities really are.

Now, where did I leave the children? 

Labour are back in power!

"And no anchovies!" Cameron gets
tough with Theresa May. Clegg rather
 likes anchovies but says nothing.

We won! We won! Rejoice! Well, when I say we won, I mean that the Labour Party won. I'm not entirely sure that means 'we' but at least it means the Tories didn't win. My enemy's enemy etc. Yes, the Tories lost and that means the end of tyranny and injustice throughout the land. Tiny Tim will live, no more cuts, no more VAT rises, no more student fees, no more public executions...

I don't think I am over-stating it when I say it's the constitutional equivalent of destroying the Coalition Death Star - or were the Coalition the goodies? I don't know and, frankly, this is no time for fact checking. Darth Cameron and his stormtrooper Jabba the Clegg have seen their forces routed by the cuddly new E 'wok' Miliband...What are you saying Chewbacca? The Coalition hasn't collapsed? The Death Star wasn't destroyed?  We are still facing a winter feeling the full force of the cuts.

Always bad news

Well, looking on the Mr Brightside at least that's one less seat that Labour have to win. Two less for the Coalition majority. We're a step closer to the promised land and a new era of hope and fair government. What is it Lassie? You mean Labour already held the seat? Labour won the seat in May but a special court found ex-Labour minister Phil Woolas made false statements about the Lib Dem candidate and the result was declared void. So Labour won a seat they already had. Even so, Lassie, it's a morale boosting result for everyone who opposes the evil Coalition.

Time at least for a few rousing words to Labour's Rebel Alliance massing on Saddleworthonia. Time for one of those inspiring speeches that Eddie M has become famous for, here it comes: "I think the voters of Oldham east and Saddleworth have sent a very clear message to the government about some of the things they've been doing" 'Some of the things,' Eddie? Only, 'some of the things'? Well, that showed them. What a battle cry. It's like Father Ted's "Down with that sort of thing."

In case you don't recognise him
- this is the less well known Miliband

We don't like 'some of the things' the government is doing! How very considered. Which bits do we like? "We don't like the cuts and stuff but we do really like the new wallpaper in the Cabinet Rooms." Hang on, don't panic, there's more: "But more importantly, I hope the government will listen to what they've said about those key issues." You tell them Eddie, I 'hope' they listen too...but what if they don't?" Here comes the knock out blow: "This is the first step in a long journey for Labour." Sorry, but I feel a bit depressed now. I think I might go home and cry...

More importantly, at least the the Lib Dems lost, and if there is one thing we dislike more than Tories, it's the Parliamentary Liberal Democrats. I say 'Parliamentary' because, to show I am not a complete bigot, I want to admit that some of my best friends are Lib Dems. It would be a bit awkward in Bathavonton to get the right numbers for dinner parties if we could only invite Revolutionary Syndicalist Reactionaries like ourselves. To the RSRs, any agreement on a time or a menu for dinner would signify an acquiescence to bourgeois bureaucratic tendencies and would require an immediate programme of re-education.

In the old days, Liberal dinner guests always seem so easy to please. Always on time. So polite. Never overstay their welcome. They may not always have agreed with the principles of the RSR, but at least they expressed the appropriate level of guilt for their divergence from the the correct ideology. They were keen to assure everyone, 'that they had heard Bash Street Comp was very good, it's just that Eton was a family tradition.' Inviting a Lib Dem to dinner used to be like inviting the punchline. The Party were so charmingly ineffectual, you just had to vote for them occasionally. Their conversion to the 'dark side' has been like discovering that the little boy you sponsored through school turned out to be one of the Taliban. But now we know what they are really like we won't fall for that again...will we?

Skip - "You are dumber than a sheep"

Hang on Skippy, you must be mistaken. The Lib Dem share of the vote went up? THE LIB DEM VOTE WENT UP? Obviously, a party that has proved itself to be utterly untrustworthy and lacking in any moral fibre has become more popular. Of course it has. Now that it is clear that the Lib Dems are led by two of the most cynical and self-serving politicians of our time - against some very strong opposition - it is obvious that they should gain the respect of the British electorate. In fact, looking at the result, it appears that Clegg and Cable's duplicity has been so pronounced that a lot of confused Tories ended up voting for them. What colour do you get if you mix blue and orange. It can only be a matter of time.

Canthingsonlygetbetter?

Land of my Pilgrim Fathers - Boston Lincolnshire

"We're the forgotten town" says my brother. It's a common refrain as I speak to members of my family. Once the second biggest port in England and a hotbed of radical religious fervour that influenced the world - it is now a traffic clogged backwater. As someone who left the town 22 years ago it seems fitting that nowadays the towns greatest historical legacy is to be known as a place that people escaped. When the Pilgrim Fathers (who were imprisoned there) arrived in America they chose to name their home Boston.

Yet, 'forgotten town' seems an odd label. Over the last few years, for a small market town of only 60,000, Boston has attracted a remarkable amount media attention - none of it good. Firstly, Boston United, the local football team, attracted attention for making illegal payments to players and avoiding tax. United were subsequently relegated three leagues in two years. The chant from the terraces of 'who ate all the pies' was easy to answer because in 2006, Boston was named the fattest town in Britain with 31% of its residents clinically obese.

The growth in its population was not just around the waist. In 2001 96% of the population were regarded themselves as 'white' British. After the expansion of the European Union in 2004, Boston saw its population grow by 25% in just a couple of years. Although wages are very low in the area, migrants from Eastern European countries with even lower wages were were attracted by the prospect of working on the farms and in the food packing and processing factories. According to Refugee Support, 95% of local employers use casual labour and 98% is immigrant labour.  In 2008, Hazel Blears, then Communities Secretary,  confirmed to a Commons Select Committee that one in four people were from Portugal or Eastern Europe and an incredible 65 languages were spoken. 

Much attention, and rightly, has been given to the plight of the new 'Bostonians'. In 2007, The Independent ran a story, 'Immigration: In the town where the gangmaster is king.' Gangmasters are contracted to provide labour for the agricultural and horticultural industry. The Reverend David de Verny, former Chapain to migrant workers, was very critical of the system, "Two hundred years after the official abolition of slavery we are treating foreign workers like slaves. We are only interested in them as economic commodities."

Verny's concerns seem to be borne out by the practices of the gangmasters. The Independent reported they had a 'very holistic approach to "caring" for their workers – getting the wages back by selling them housing, food from their own shop, vodka or hard drugs, or prostitutes. Marta, a 28 year old from Warsaw said, "The gangmaster system rules the town. It is a total disaster. People work for 12 hours, seven days a week, for very little money. All the Poles live together in overcrowded houses paying ridiculous rents to the gangmaster. They travel together and they have no money or time to learn English. What chance do they have?"

Little has been said, however, about the problems that this huge influx of immigrants has brought to the town. Maggie Peberdy of the Citizens' Advice Bureau, noted that, "If you're 50 years old and have been working for the same company for a long time, you're in big trouble. You may be getting slow and a bit arthritic, but the boss can get in a Pole who is younger and faster. He will work seven days a week, at all hours, and he'll be paid piecemeal with no sick pay, no holiday pay, nothing. Unless you accept those terms too you may be out of a job." The immigrants have enabled the producers to keep wages low. 

The strain is being felt in a number of ways. Last year a Boston Headteacher warned that, soon, 60% of pupils will be from immigrant families. A police report in 2006 highlighted that Eastern European 'mafia-style gangsters were organising prostitution. In a stop and check operation, Lincolnshire police found 50 per cent of all drivers were committing an offence and 97 per cent of those were migrant workers. The police noted 'a marked increase in road traffic accidents in this rural area.' Boston had also seen a rapid increase in house prices because gangmasters were buying homes to house their low-paid workers. The council estimated the average two-bedroom house price has risen 400 per cent in six years with the  ‘ghettoisation’ of some areas. 

Advice worker, Maggie Peberdy explains, "There are things you can't talk about because you get accused of racism. "One is housing. There is a myth that they are all young, fit and single, but if you put people like that together in vast numbers they soon stop being single. They make couples, and then babies. They may have to be considered a priority for housing help. Their needs will be perceived as greater than those of local people, who may get upset." As The Independent pointed out, these are the words of someone who has demonstrated a commitment to helping the immigrant population. The Telegraph reported last year that the recession has not seen the migrants returning home. Boston is now officially the fertility capital of Britain with an average of 2.8 babies per woman, thanks largely to the new immigrant families. 

All public services have been put under pressure by the population growth and by the challenges of dealing with people who don't speak English and have different cultural expectations. Remember, this is a rural and very isolated part of the country. When I was at secondary school I was regarded as an ethnic minority for having an Irish grandfather and being a catholic. Don't underestimate what a culture shock this has been for everyone concerned. Current estimates suggest that there are at least 66,000 people living in the borough. Yet government funding is based on the data from the last census which showed 54,000, no wonder services are struggling to cope. In the circumstances, it seems quite an achievement that there has not been more tension in the town. 

Visiting Boston from Bath is a pretty big culture shock, even for someone who was raised in the town. It feels like venturing into a rather dystopian vision of globalised Britain. It is a town that feels deprived. Lacking money, yes, but to a large extent direction and hope. The election, in 2008, of a BNP candidate to the Fenside Ward, on Boston Council again drew the media, but, the BNP's victory, while no doubt reflecting a degree of racial tension, with a poll of just 279 votes on a turnout of 22% it was hardly a racist mandate. What the media missed and is more interesting, I think, is that 25 of the 32 council seats are controlled by independents. There is a general feeling that the mainstream parties just aren't interested in Boston people or their problems.  

What are the problems? For me, it's not about race, it is about poverty. Towns like Boston reflect the two-tier society (at the very least) that we are creating. Boston and towns like it are an indictment of how working class people have been badly let down by the Conservatives and New Labour over the last thirty years. Whole towns are simply being left behind. Can we afford to allow whole boroughs to disengage from mainstream politics? Their 'ultimate solutions' might be even less palatable than the BNP.

Now, can I eat all the pies, please?

Conservative reform and the baying mob

In Pakistan, Aasia Bibi, a mother of five, has been sentenced to hang under Pakistan's blasphemy laws.  Meanwhile, in the UK, the Tories are keen to push through a series of reforms that promote decentralisation, devolution and empowerment, to create what David Cameron calls an, “empowering state” rather than an “overpowering state.” Rather than debating the horror of double glazing in a grade two listed house, Bibi's story confronts some of the big questions about how a society should be run. Religion, class, and human rights. Bibi's life. Yet, Bibi's plight could hold a warning to Cameron and his allies.

The 'localism' proposals cut across a range of policy areas: in crime they propose to make police locally accountable to a directly elected individual and will oblige the police to publish detailed local crime data statistics every month hold the police to account for their performance. In health reform Primary Care Trusts are being dissolved and responsibility for commissioning services will be given to local GPs. With the reform of the National Institute for Heath and Clinical Excellence (NICE), the decision about what drugs a patient can access will be left to the doctor. In planning, local communities will be able to propose development which, if it meets certain safeguards and gets 50% of support in a local referendum, will be  built without planning permission.

In principle, this all sounds perfectly legitimate. However, as the BBC's Nick Robinson said in his blog recently, "Governments with money centralise and claim the credit. Governments without cash decentralise and spread the blame." In practice, the Tories are passing over a lot of responsibility and tough choices without providing the money to carry out the new duties properly. The medical reforms are a good example. Health Secretary Andrew Lansley has confirmed that Primary Care Trusts are to be abolished by 2013, from when GPs will plan hospital care and manage budgets. The PCTs will be replaced with 500 GP consortia.

The exact proposals have yet to be published but the overall effect will be to leave far fewer people  without the appropriate training or experience, with a smaller budget, making some very tough decisions about local priorities. Not only will the GPs on the consortium have to work alongside colleagues struggling with their own set of priorities, they will also come face to face with patients each day. The nature of the job also means that GPs tend to be prominent people within the community. GPs and the consortium members, in particular, will no doubt be subject extreme personal pressure from individual patients and organised groups.

On the back of these reforms, the Conservatives intend to strip NICE of the power to turn down new medicines. NICE ensures that the drug budgets within the NHS are used in the most cost-effective way. The power to turn down medicines was a response to the postcode lottery when some patients could get treatment and others couldn't. The pharmaceutical industry has always been critical of NICE and must be rubbing their hands with glee at the thought of influencing local GP consortia to provide more expensive treatments.

Dr Clare Gerada, chair of the Royal College of GPs, attacked the propsals:


"GPs will bare the brunt of the proposed £20 billion savings. I'm concerned that my profession, GPs, will be exposed to lobbying by patients, patient groups and the pharma industry to fund or commission their bit of the service. There could be letters from MPs and patient groups, and begging letters from patients. At worst, the negative impact for GPs could be patients lobbying outside their front door, saying, 'You've got a nice BMW car but you will not allow me to have this cytotoxic drug that will give me three more months of life.' Patients might think that the decision made about their healthcare will be based on self-interest – GPs saving money for themselves rather than spending it on patients. Certain treatment decisions, and a GP consortium's need to balance its books could be misconstrued...Making GPs "the new rationers" of NHS care could ruin the long-established bonds of trust between them and their patients." 

The fact is that whether we like it or not, the NHS has a limited budget and there is an opportunity cost for every decision made. That is, for every new cancer drug that provides perhaps a year of life, a seemingly more banal but long term and life enhancing treatment may be denied. There is a choice. Do you want to make the decision between extending a life temporarily or providing a number of hip operations? Such decisions require objectivity, careful un-emotive planning away from frontline pressures.

Meanwhile, in Pakistan, Bibi's case is the first time a woman has been sentenced to death for blasphemy. It has provoked a cleric in Peshawar to offer a reward of 500,000 rupees (£3800) for her death and has led to the murder of Punjab governor Salmaan Taseer by one of his own guards. The liberal governor had dared to take up Bibi's cause with the president and condemn the blasphemy laws. His death prompted a 'rally against fear' but as Declan Walsh noted in the Observer yesterday, politicians in Pakistan are 'terrified of being on the wrong side of the blasphemy debate.' The government has subsequently confirmed that they will not repeal the laws.

In her home town of Itanwali, Walsh reported that the local people are growing impatient for the sentence to be carried out. However, it appears unlikely that Aasia Bibi will be hanged. Despite this atmosphere of fear no blasphemy convict has ever been hanged in Pakistan. In 2001, Dr Younus was accused of defaming Muhammad. His conviction was finally overturned by the Supreme Court. In fact, according to The Observer,  most blasphemy prosecutions are overturned by the appeal courts, which are to some degree immune to the pressures of the mob that afflict local benches. Usually the judges simply find that there's no evidence to support the case.' In other cases the defendants have received a presidential pardon.

There are enormous differences between Pakistan and the UK but I think the case flags up some important issues for policy-makers. The rush for local decision-making needs to be considered very carefully.  Do we want our health priorities decided by the marketing department of the drug companies or by the local organisations who shout the loudest? As the Tories rush through their 'localism' reforms, I think the lesson of the Bibi case is that only authority, size and space can create the robust decision-making that is 'immune to the pressures of the mob'.

It's a matter of life and death.