Category: Politics UK

Reflections on general political developments and ideas in the UK

A brief guide to Keynesianism and the economic crisis

Hardly a day goes by without the dead British economist John Maynard Keynes being invoked, such as this article from this morning’s Independent.  Generally it is the critics of austerity that use his name, although this article is more nuanced, blaming George Bush and Gordon Brown for getting us into this mess by ignoring Keynes’s prescriptions.  And many more economists, including big names like Paul Krugman, use ideas that most people understand as “Keynesianism” even if they do not evoke the great man directly, rightly thinking it is better to appeal to logic and evidence rather than dead men, however great.  Inevitably a lot get taken for granted in these arguments.  For the benefit of amateur economists like me, in this long posting I want to explain and re-examine Keynesianism, in order to assess its relevance to the current crisis, especially here in the UK.

What do we mean by “Keynesianism”?  It is the idea that government fiscal policy, public expenditure and taxes, should be used to counteract a deficiency in demand in the total economy.   It originated with the insights of the great economist, and his reflections on the Great Depression of the 1930s.  Its starting point is that a whole economy does not work like a household budget.  It may be very sensible for a household to choose to spend less than it earns, but a whole economy cannot do this.  Supply must equal demand; you cannot store more than a trivial amount of production from one period to the next.  If across a whole economy more people want to spend less than they earn, in other words to save, then there isn’t enough demand to meet supply and the economy must shrink; people are put out of jobs and so on.

Not so fast.  Things balance out of the net saving can be channelled into investment.  Investment, in economics, refers to production for future benefit.  This usually refers to business investment (machines to make future production more efficient) but can also refer things like building houses which are “consumed” over a long time period .  But if savings are not matched by investment there is trouble.

The possibility of trading with another economy complicates the picture, of course.  Net saving can be balanced out by net exports.  But net exports across the world economy are zero, so this option isn’t available to everybody.

In classical economics there is no lasting mismatch between savings and investment, because markets balance the two out.  If there is too much saving, then this stimulates the supply of investment opportunities, for example by reducing the rate of interest.  Keynes’s great insight was to see that often this market mechanism doesn’t function properly, leading to prolonged unemployment.  And unemployment is a waste; production lost forever.  Much better to use this surplus labour inefficiently than not at all.

Extra spice is added to this logic by the idea of the multiplier effect.  If, for example, you stimulated the economy by paying extra benefits, then the recipients of the benefit would go out and spend them, and the people receiving this spending will spend more in turn, creating further demand and so creating more work.  The same logic applies in reverse; austerity tends to multiply itself too.  This effect is probably what students remember best about Keynesianism.  It gives the idea of Keynesian stimulus gravity defying properties – so that government spending on stimulus can pay for itself in extra taxes generated by multiplied demand (and the reverse, of course, with cuts being self-defeating).

Keynesians point to the Great Depression as an example of how things can go wrong, where excessive austerity turned a setback into a disaster, only rescued by the War (and what could be more wasteful than fighting a war?).  Critics of this view, incidentally, point out that the primitive state of the world’s banking systems had a lot to with this disaster, and so you can’t really compare it to now.

After the war, demand management by governments using fiscal policy became pretty much the orthodoxy.  But this went wrong in the 1970s, when a Keynesian response to the oil crisis simply led to rampant inflation, rather than reduced unemployment.  What are the problems?

First of all, Keynesian stimulus can’t push an economy beyond the limits of its economic infrastructure. To do so simply creates inflation.  After the oil crisis disaster, economists modified their ideas to take account of this, bringing in such ideas a as a “natural” level of unemployment, and giving a major role to monetary policy alongside fiscal policy.  This set of ideas became “neo-Keynesianism” and the orthodoxy of the 2000s.  It was what I was taught in my macro-economics course in 2005-08 at UCL.

A more subtle criticism is that fiscal stimulus is undermined by human behaviour.  If people respond to extra money in their pockets by saving more, the stimulus effect evaporates.  An idea of “Ricardian equivalence” has been developed to postulate that extra government spending would always be offset by extra saving, because people know it would lead to more tax, for which they must save.  Responding to this, proponents tend to suggest stimulus to areas where this is less of a risk.  For example, benefits to the hard up, rather than tax-breaks for the rich.

Another idea, in floating exchange rate economies like Britain’s, is known as the Mundell-Fleming effect, which predicts that fiscal stimulus simply causes the exchange rate to appreciate and crowds out exports (or is lost in imports).  This idea is quite difficult to get a grip on, and anything to do with predicting exchange rates turns out to be impossible to prove.  But it does offer an explanation of why the pound appreciated after British government’s stimulus programme following 2001.  And the basic idea that fixed exchange rates undermine monetary policy while floating ones undermine fiscal policy has the undoubted merit of symmetry.  So British austerity should be offset by a lower pound which stimulates exports.  The first part of this prediction seems to be working, but the second is slow to come about, not least because so many of our usual trading partners are in crisis too.

But the strongest objections to Keynesians come from the so-called “Austrian” school, because its more famous advocates (Schumpeter and Hayek in particular) were born in Austria.  This sees unemployment as a essential to a process of creative destruction, as inefficient and unwanted businesses go to the wall, to be replaced by better ones.  Keynesian stimulus interferes with this process, in particular by leading to wasteful investment; any temporary relief is offset by longer term problems.

From within the neo-Keynesian camp there are also those who advocate the use of monetary policy to manage the business cycle, as being much more efficient and effective that fiscal policy.  These seem to include the British Chancellor of the Exchequer, George Osborne.

So how to apply to the current economic crisis, and in particular to Britain?  The first point is that the pre-crisis economy was built on false premises, with unsustainable borrowing and a property boom.  It cannot be recreated by applying stimulus.  Not everybody accepts this, but almost everybody without a political axe to grind does.  The serious Keynesian argument is not about stimulus, but about the effects of austerity.  Austerity policies are reducing demand, setting up a multiplier effect and causing pointless unemployment before the replacement jobs can be created.

It helps the Keynesians that there does not seem to be a big risk of inflation – or not wage inflation, anyway, which is the critical issue.  This seems to be held in check by strong market forces, in the developed world at least.  High price inflation in Britain is not matched by pay inflation, and it is much more about forcing Britons to accept a lower standard of living as a result of a lower pound and shortages of key raw materials.

Advocates of monetary policy are also in a weak position.  It simply does not seem to be all that effective.  Interest rates are rock bottom, and all quantitative easing seems to do is to keep asset prices at unrealistic levels.

Would extra saving undermine a looser fiscal policy?  Britons are heavily indebted, after the borrowing binge.  That might encourage them to save any stimulus money – but it also suggests that they can’t respond to lower income by borrowing more.  Since we are talking about simply slowing a downward trajectory, the latter is the more relevant argument.

For me the most persuasive case for some kind of Keynesian influence on policy is made by the Financial Times’s Martin Wolf (behind the FT paywall).  This goes back to first principles.  Consumers are over indebted and need to spend more than they consume.  Business confidence is low, which means that it is difficult to persuade businesses to invest.  The potential for more exports (or less imports) is certainly there, but is limited because to many other economies are trying to play the same game.  So we are exactly in danger of the doom loop of excess saving that Keynes worried about.  The government’s massive deficit offsets these problems to a great extent, but reducing it too fast could well lead to excess unemployment.

But we don’t know.  Austerity policies are stronger in rhetoric than practice.  We can’t avoid major cuts to government services, so there is something to be said for getting them over with as quickly as practical.  But there is also something to be said for having a “plan B” should unemployment start to escalate.  But if the government had one, they wouldn’t tell us.

Cutting VAT is one idea, advocated by Labour Shadow Chancellor Ed Balls, since it is quite likely that it will stimulate some extra expenditure – though it is very unclear by how much.  That is probably too much of a humiliating U-turn for the government.  But it is a better idea than cutting the top rate of tax, advocated by some Conservatives, since that is unlikely to have much immediate effect on demand, even if it does have longer term benefits.  Another idea is to ramp up investment projects – but it is very difficult to do this efficiently in the sort of quantities that would have a major impact on the overall economy.  Personally I would favour a go-slow on benefit reform, which is where a lot of the cuts are focused, since mostly benefits get spent.  Given how tricky this programme is already, it might happen anyway.

It would not be surprising if the government missed its deficit reduction target over the five year term.  What will not be clear is whether this happens because Keynesian policies were applied (i.e. by slowing the pace of austerity) or because they weren’t (i.e. austerity strangling the economy at large).  That won’t stop people being firmly on one side of the argument or the other.

Economic growth and the media circus

Today the ONS released their first estimates for economic growth for the second quarter.  These quarterly figures have become the centre of a media frenzy; the papers and the BBC have been speculating about them and their implications for days.  Some commentators have worked themselves up into a real state, saying these numbers will be critical to the government’s future (see this comment on one which gives quite a good idea of the general coverage before the figures have even been released). This is getting very silly.

The first problem is that these numbers aren’t very accurate; the second is that they don’t mean very much to ordinary people anyway.  GDP, and the growth figures based on them, have become very interesting to economists, especially in making comparisons between countries, and looking at trends over a period of time, and compiling all manner of ratios.  But they are obscure aggregates that mean very little to us day to day.  The economic statistics that matter are those on unemployment, pay rates and consumer prices.  Taken together these figures give you a much better idea of what life is like for real people.  Further light is thrown by various other measures, like trade figures, retail sales and so on, though these are bit too volatile for single month’s figures to mean very much.

These statistics are painting a clear enough picture of the British economy.  Unemployment is high, especially amongst the young, though not as bad as in previous downturns.  It remains steady, with employment overall growing.  Inflation remains persistently high, largely thanks to higher import costs and taxes.  Remarkably, average pay is not keeping up with inflation, so we know that people are being squeezed.  The fact that so much of the squeeze is being spread across the working population, rather than concentrated in rising unemployment, is the truly remarkable thing about the economy right now.  This is surely a better way for the country to adjust to the new reality.  But it does mean that gloom is spread far and wide.

The government should really start to worry if one of two things start to happen.  First that unemployment starts increasing again.  Second if pay inflation creeps up beyond about 3% (it is now about 2%), since this means that an inflationary spiral might be on hand, so interest rates have to go up.  Likewise they should start to feel relief if and when unemployment gets significantly lower, and when inflation falls below 2%.  The betting is that the economy will keep bumping on somewhere in between the good and the bad news for some time to come.

Meanwhile there is a very unedifyng argument about the economy going on, with people talking at each other without any serious attempt at improving their understanding.  Consider this little discussion on Lib Dem Voice to which I made a couple of contributions.  I think the founders of economics as a social science hoped that it would improve people’s understanding of the world around them, but so often economic arguments are just used as ammunition to support prejudices.  And you can use them to argue just about anything.

All the more reason to ignore the media coverage of the quarterly growth figures.

Affording the NHS

The British government has been talking darkly about the exploding demands on the National Health Service, which will rapidly make it unaffordable if it is not reformed.  This has recently been challenged by Professor John Appleby, at the health think tank King’s Fund.  This was in a recent article in the British Medical Journal, behind a paywall, but summarised by the BBC here.  This question goes to the heart of health policy in the UK, but politicians dare not discuss it – because it puts the very principles of the sacred NHS in question.  But the problem will not go away.

According to some figures on Wikipedia Britian spent an unremarkable 8% of its national income on health, compared to over 16% in the US, before the financial crisis struck.  Those figures will be higher now, since our income has shrunk, but the relativities will be much the same.  The comparison between the two countries is usually held up to show how ineffective US health spending is, since health outcomes look generally pretty poor there.  But the comparison can be looked at the other way.  The US can afford to spend more than 16% of its national income on health and still remain one of the most prosperous countries on the planet.  There is nothing mysterious about this.  Developed countries are long past the level where basic human needs of food and shelter are met; how we choose to spend the surplus is up to us, and there is no reason why we can’t choose health care over cars, designer clothes or big holidays.  It’s not as if it requires massive imports to sustain it.

You can take this line of reasoning further.  The basic proposition of health care is to reduce pain and prolong life; these are consumer propositions to, well, die for.  Suppose we lived in the economist’s free market utopia, where health spending was a matter of individual choice in a perfectly competitive free market with no information asymmetries.   There is no reason to think that health expenditure would not be higher than the 8% or so we currently spend in Britain, or indeed as high the US figure.  We can perfectly easily afford it.

That’s not the problem.  The problem is paying for it almost entirely through unspecific taxes, the core design principle of the NHS.  And here the government is on much stronger ground.  There is an upper limit to how much tax we can raise for health care.  Up to a certain point, of course, the NHS model works perfectly well.  Look on the taxes as an insurance premium and it helps spread risk in a way that people like.  But the more you spend, the more the weaknesses of the model are exposed.

  • There is no direct line of sight between what you pay and what you get.  How on earth are you supposed to decide whether you are getting value for money?
  • You have no choice in the level of service you get.  One size fits all.
  • People who are better off may feel that they are paying too much relative to what they get.  This may not be quite as strong an argument as it first appears, since the less well off pay a lot of tax through cigarettes, alcohol, petrol and VAT – but the perception is still a problem.
  • Taxes create a drag on the rest of the economy, reducing incentives to work and therefore shrinking the resources available.

America is able to get away with much higher levels of health expenditure because so much of it comes from private insurance premiums and direct private payments for treatment.  But even there a battle royal is developing over how to balance taxes and government support.

Of course, to some putting up taxes is the right way to go.  France and Sweden get away with higher tax burdens than the UK after all.  But this is very fraught.  Some think you can go after big companies and very rich people and leave everybody else.  This is not as easy as it sounds though, since this wealth is very mobile.  Property is not mobile, of course, but raising taxes on property is probably as politically toxic in Britain as taxing fuel is in the US.  There is also a problem if too much tax revenue comes from the very rich or corporations – these start to acquire more political weight.  Which leaves the not-so-rich.  But these people are under pressure and feel over-taxed – Ed Miliband’s “squeezed middle”.

So I think the government is right.  We have hit the limit of what the country can afford for tax-funded free-at-the-point-of-use health system.  But we have not hit the limit of what people are prepared to spend if it’s their own money and for their own benefit.  The risk to the NHS is that the more affluent middle classes start to opt out of NHS services, depriving them of critical mass and undermining the principle of social solidarity.  This has already happened to NHS dentistry.

Nasty.  In the last years of the previous government the issue of co-payments was quite high up the political agenda: the possibility of NHS patients topping up their treatments with their own money to get things not on the basic menu.  This had become politically charged because of the costs of some rather questionable cancer treatments which the NHS were denying but which people were prepared to pay for.  The Conservatives clearly considered the topic politically toxic, since they have fudged the issue of cancer treatments with a bit of extra funding.  Labour and the Lib Dems were inching towards accepting co-payments, though I expect both parties are now bouncing back.

But in my view co-payments is the best way to relieve the pressure.  The NHS should define a basic menu of treatments that everybody is entitled to, but accept payments for anything outside this.  This undermines one of the sacred founding ideas of the NHS, that everybody gets the same, no matter how wealthy.  But it is better than the alternatives.  It’s the debate we should be having.

Hacking scandal – enjoy it while it lasts

We haven’t seen anything like this since the MPs expenses scandal in 2009.  Rupert Murdoch’s newspaper empire is the centre of a media and political feeding frenzy provoked initially by outrage over mobile phone hacking, and now taking in dodgy relationships with the Police and management cover-up and dissembling.  Murdoch has had to close one highly successful paper, and now he’s  withdrawn his bid for 100% of BSkyB.  Commentators are using metaphors such as earthquakes and the shifting of tectonic plates.

Frankly I find it impossible not to enjoy this spectacle.  Murdoch and his acolytes are hard-nosed businessmen who would not have thought twice about meting out the sort of stuff they are now victims of.  We can only imaging what The Sun would be saying about the photogenic Rebecca Brooks, the senior manager at the centre of the scandal, where it not part of the Murdoch empire.  What’s more Mr Murdoch clearly had undue political influence, and liked hold politicians in fear – and now it is wonderful to see how politicians behave once that fear is lost.  And his influence was in no way benign, in favour of biased news, extreme Euroscepticism, and stoking up prejudice generally.

But will any lasting good come of it?  It doesn’t bother me that other, equally evil press barons have so far escaped unscathed.  Indeed widening the scope might diminish the punishment – it is surely more effective to totally dismantle one evil empire than damage several a bit.  The others will draw conclusions from Murdoch’s fate.

But the political earthquake of the MPs expenses scandal did not change very much, after its deserved and undeserved victims were buried.  The same prejudices and appetites that Murdoch fed on persist.  Others will move into any empty space that he vacates.  And it is almost impossible to regulate it properly.  It is difficult to believe that the public enquiry will change very much.  Indeed the political consensus around keeping its scope very broad might serve to weaken and dilute its effect.

But in amongst this battle there is one thing worth fighting to protect.  That is the regulation of news broadcasting in TV and radio, and the primacy of the BBC.  As this Bagehot column makes clear (see the end of the article), Murdoch clearly wants to establish a Fox News in the UK to do to TV what his print newspapers have done to that medium.  The BSkyB takeover was part of that strategy.  The baleful influence of this is all too clear from this poll which shows that TV and radio are the only medium that retains a high degree of trust in the UK, and that distrust of the press here is much higher than elsewhere in Europe.

The savages were circling.  They’ve been seen off for now.  But we must stay vigilant.

Is Britain about to go bust?

The debate about Britain’s economic policy rumbles on, with a speech by the Shadow Chancellor Ed Balls last week.  In previous posts I have dismissed the claim made by some that the government’s cuts are unnecessary, and most commentators, including Mr Balls, seem to accept this, even if they don’t say so explicitly. But there is a furious debate about how quickly the cuts should be implemented: 5 years as the government plans, or 8 years as Labour suggests, apparently including Mr Balls, though in the past he has been suggested longer.  An impressive array of economists seem to support the Labour argument.

The basis of the critics’ argument rests on conventional macroeconomics, and runs that cutting too fast creates needless unemployment and risks a spiral of lower demand which will make things worse.  This argument is open to challenge on its own terms (see The Economist’s Buttonwood column here, or Bagehot here), but the government’s defenders don’t generally try; instead they trump it with an argument about unsustainable levels of government debt.  I want to look at the macroeconomic argument in a future post.  Today I will consider whether unsustainable debt really is such a risk.

If government debt gets too high, it can derail the whole economy.  A default, when governments renege on the terms of their debt, can be absolutely catastrophic.  The problem is that if governments can’t raise the money then all the functions of government are threatened.  For countries like Greece who are part of the Euro, this means that they literally can’t pay the bills – salary payments are stopped and so on.  This is such a frightening prospect that there are strong incentives for other members of the zone to organise a rescue.  Countries like the UK do have another option: they can debauch their currency by paying bills with newly created money.  That’s how hyperinflation starts; the most recent example is Zimbabwe, and its implications are hardly less disastrous than default.

So what are the risks for Britain?  The good news is that before the crisis struck overall debt was modest by international standards at a shade over 50% of GDP.  Even better, the maturity profile of this debt, i.e. how soon it has to be rolled over, was long term – longer than any other major economy.  The bad news is the massive size of the current deficit – 11% in 2009, and the fact that 8% is “structural” or won’t bounce back with the economic cycle.  That means that total debt is increasing rapidly; by the end of 2010 it was already 75% of GDP. This gives two main problems.

The first problem is that debt risks spiralling out of control.  Few think that the current economy is capable of more than modest growth, austerity or not, which means that extra wealth is not being generated fast enough to get us out of trouble.  And debt comes with an interest bill.  There are some classic economic models of this, and on these the warning lights are flashing red furiously.  At some point lenders (characterised as the “bond markets”, but potentially including you and me) refuse to lend, or at least start to put the rate of interest up, making things worse.

The second problem is more subtle.  If total national debt levels off at a high level, this will drag down the whole economy for a long while to come, as we spend too much resource servicing the debt.  One study suggested that serious problems start to happen when debt reaches 90% of GDP – less than two years away at the current trajectory.  Taking longer to eliminate the deficit means that overall debt will level off at a higher amount, unless the aggressive option really does lead to meltdown.

There are three further overlapping problems for the UK.  Debt markets are very open; there is a degree of dependence on overseas support; and the pound is a floating currency.  Government debt problems are much easier to handle if there is ready access to lenders who are effectively forced to lend to you; this has helped such high debt countries as Japan and Italy.  Superficially the UK seems to look this way: pension funds are massive, and traditionally hold lots of government debt (gilts) for actuarial reasons.  But such funds are aggressively and independently managed, helping to make our financial services industry internationally competitive.   That means they switch away from buying gilts as soon as they think it is not such a good deal.  Dependence on overseas investors appears to be relatively modest, as buyers of gilts are overwhelmingly domestic (or so I believe).  But the country still runs a significant current account deficit (unlike Japan, and even Italy), meaning that the economy as a whole does need foreign lenders.  The floating pound is often presented as a get out of jail free card – but the benefits of being able to devalue are two edged.  Foreign investors will be wary of sterling if they think it will devalue; domestic investors will likewise increase their overseas exposures in the same event, reducing their ability to buy gilts (unless these are  issued in foreign currency, but let’s not go there).

But, the government’s critics maintain, there’s no sign of trouble, and never has been.  The government has had no trouble selling gilts, at very low interest rates.  The trouble with this argument is that markets can turn in an instant, and you won’t know until too late.  An investment decision depends on a judgement looking far into the future, and this can move very quickly.  Government ministers seem to have got a genuine fright in May 2010 with the Greek crisis.  By and large the closer a commentator actually is to the debt markets, the less sanguine they are about the whole thing.  There are just too many risk factors.

So what to think?  The Labour plan is probably viable, if backed by a real determination to follow it through (and Alistair Darling, the outgoing Labour chancellor would have been an excellent figurehead, unlike Mr Balls).  But it undoubtedly takes more risks with catastrophe.  Whether it is worth doing so does come back to your view on the macroeconomic risks.  If you think that the austerity programme really will lead to meltdown, then this has real power.  But neither is the government argument implausible.  It’s about the risks you are prepared to run.

Why are NHS managers so unpopular?

Health Service Journal (HSJ) was on its high horse last week.  Its front cover says “The Big Lie exposed: the truth about NHS management”.  The proximate cause is a report by the King’s Fund called The Future of Leadership and Management in the NHS.  This report suggests that the NHS doesn’t have too many managers, and that, if anything the service is under-managed.  The HSJ is directed at NHS managers, and it is easy to see why they are so fed up.  But the HSJ coverage has a blind spot.  It doesn’t ask how the NHS got itself into this situation, and why NHS managers have become politically toxic.  It’s no use waving around King’s Fund reports; if NHS managers don’t understand of this, they will struggle to reverse it.

But let’s clear the decks first.  The idea that the NHS has too many managers as opposed to those “front line” staff is silly, and the political target to reduce their number is at best unhelpful and at worst positively damaging.  In order to deploy those front-line resources most effectively, they need to be properly managed.  Huge strides have been made by the NHS through more and better management over the last couple of decades.  Furthermore, my impression of the quality of NHS management is that it is easily up to the same quality as the private sector.  That, of course, is not as much comfort as it might be, given that crass management is pretty rampant in the private sector.  So a lot of the political comments made about NHS management are unjust, unfair and often just plain untrue.

So what’s gone wrong?  Well a clue comes in the frequent use of the word “bureaucrat” by politicians.  This is a word thick with negative connotations, of insensitivity to people’s real needs and of the arbitrary exercise of power.  Many of the public’s interactions with NHS management have left just this sort of impression.

The NHS is a hierarchical organisation, with pretty much all accountability through a single man at the top, the Secretary of State.  To most people this is no accountability at all.  One man can’t possibly grasp the intricacies of any particular local situation.  So local NHS officials have huge amounts of effectively arbitrary power.  And they rub our noses in it.

When the local NHS where I live executed a 180 degree turn and decided to close a local hospital rather than develop it, they rode roughshod over local feeling.  A local official just told us the area was too posh to have a hospital.  After a kerfuffle involving the local Labour (at the time) MP, more facilities were promised nearby in an appropriately less posh place – but of course these were soon cut, even before last year’s election.

The problem for most NHS managers is, I think, that they don’t remotely get what the problem here is.  Tough decisions have to be made.  If we followed local opinion all the time the NHS would go bust in days; if we kept consulting nothing would get done.  We have clear mission and we execute it.  NHS managers seem to bristle at the idea of genuine local accountability.  HSJ itself opposed the Lib Dem proposal of directly elected health boards.  Chaos.  Postcode lotteries.  Working for people that don’t understand.  And so on.  NHS managers are all too happy with their hierarchies, allowing them to pass the blame upwards the whole time.

But the local NHS is taking political decisions all the time.  For example, reducing health inequalities, a key local NHS objective, is loaded with political judgements.  A key political objective is to maintain middle class consent for the service; without middle class users the NHS would collapse (and we already have the example of NHS dentistry to show that).  So treating them like muck because they are on the wrong side of the equality equation should be a no-no.  Politicians can see that easily; bureaucrats can’t – it’s just not their problem.

And once you are perceived as an insensitive bureaucrat, the rest follows pretty quickly.  An organisation as large as the NHS will always throw up examples of crass management, which will be gleefully reported by patients and clinical staff alike.  And if managers are overstretched, they are bound to drop some balls too.  Episodes such as the Mid-Staffs fiasco add grist to the mill (and incidentally I did not sense much outrage from other NHS managers in the HSJ coverage of that sorry affair).  Throw in the management consultant blather dropped on the NHS (World Class Commissioning and such), and you have a massive stock of ammunition.

So NHS managers need a lot more political sensitivity, and should welcome more genuine political accountability instead of resisting it.  The NHS reforms are meant to help this, though whether do, of course, is another matter.

The military covenant – let’s be careful

Am I the only person here in Britain to feel just a little uncomfortable over the so-called “Military Covenant”, given prominence by the Prime Minister over the last couple of days.  This basically holds that servicemen should be given extra respect by the rest of us because they put their lives on the line on our behalf.  This is meant to have practical consequences for medical treatment, housing and schooling for their children.  There is talk of enshrining this in law.

I don’t have an issue with these practical points.  The demands of service personnel (especially tours of duty in remote spots) place huge pressures on family life in particular, which means that it is very easy for service families to fall foul of arrangements designed for the rest of us.  It sounds as if these could do with improving.  Service families, servicemen who are injured (mentally or physically), and those making the difficult transition to civilian life, all deserve extra attention from our public services.  Mind you, I would like our public services to do a better job for everybody.

But respect?  This can’t be unqualified.  Soldiers do put their lives on the line on the public’s behalf.  But it isn’t like firemen going into burning buildings to rescue people.  We equip these people with lethal force and (in practice) some fairly free rights to use it.  In the big perspective, this power is often abused.  Sometimes soldiers (or airmen or sailors for that matter) are just careless with innocent lives.  But many worse atrocities occur, for no better reason than the individuals want to exert power.  A lot of soldiers are, well, not very nice people; that goes with the job, but we need to be careful.  Most of the worst atrocities around the world are committed by people in armed services.  It’s very easy for them to abuse their power.

The record of modern British forces is not at all bad.  But things do go wrong; we have abuses of prisoners in Iraq, for example.  And there was Bloody Sunday, of course.  But the standing of British servicemen (and women) has never been higher in my memory; perhaps there’s a bit of guilt there since we don’t really understand what we are meant to be doing in Afghanistan.  If they have maintained high standards of conduct, then they have earned their status as heroes.  But the line between hero and villain is very easy to stray across.  We must hold our servicemen to that standard.  Treat them as heroes if they uphold it, but not otherwise.

It is all too easy for people to excuse bad behaviour by their military.  Just look at how long it took for the British establishment to accept that Bloody Sunday was bad.  It’s all very difficult in the stress of combat, we say, and other countries are worse.  But all soldiers know that discipline is critical to their role.  It is imperative to our civilisation that we hold our service personnel to high standards of conduct.

Who is to blame for the UK’s economic mess?

As time passes it is clear that the UK’s economic crisis is amongst the worst of the major developed economies, though Japan may beat it on some measures.  It’s not in the league of some smaller economies, like Ireland or Greece, although a comparison with Portugal may be more nuanced.  Some people (notably Labour politicians) struggle to accept just how bad things are; others don’t get much beyond railing deficits and the National Debt.  It’s worth pausing to consider what went wrong, and to try and attribute responsibility.

What happened?  Until 2007, the UK had an astonishingly consistent record of economic growth.  This started with the departure from the European Exchange Rate Mechanism under John Major in 1992, and continued until early 2008.  Economists had taken an average annual growth rate of 2.5% for granted.  Unemployment fell, and most people felt better off, though the very wealthy did much better than the rest.  Public expenditure rocketed, with massive investment in the NHS in particular.  A recent study by the Institute for Fiscal Studies (IFS) shows that poverty was reduced, largely because of increased benefits and tax credits.

And then bang!  GDP shrank by 6% in a year, stayed flat for the year after that, before struggling to a bit under 2% growth in the year after that (taking the year to the 1st quarter from the ONS).  Forecasts are for consistently anaemic growth. This is striking.  When economies hit a recession due to a temporary shock, they bounce back quite sharply, as temporarily unused capacity comes back on stream; this is what has happened in Germany this time.  Not for us; a good 7% of the economy has vanished never to return.  What makes this particularly bad is that this 7% produced an awful lot of taxes, while public expenditure carried on regardless (with benefits increasing due to the extra unemployment and hardship).  This has left the country with a “structural deficit” of about 8%.  This is the excess of public expenditure over taxes after you strip out temporary factors; the actual deficit was much larger (it reached 11% and has now dropped to 10% per annum).  Now I’m not sure how we ended up with an 8% structural deficit after losing just 7% of GDP, of which presumably no more than half would will have been taxed.  The government was already running a bit of a deficit when disaster struck; I think that capital taxes must account for the difference, now that the property boom has disappeared.

What this comes down to is that a lot of the pre-crisis growth was not for real, and government finances were built on unsustainable foundations.  What was happening?  This phantom growth seems to have been related to a boom in personal borrowing to finance property purchases and good old fashioned consumption.  Symptoms included an over-sized finance industry (in earnings if not jobs) and unsustainable levels of consumption.

Who was to blame?  The three commonly cited answers are everybody-and-nobody/events-beyond-our-control, bankers, or the Labour Government.  Some Labour politicians still seem to subscribe to the first idea.  It was an international storm (I never want to hear the phrase “perfect storm” again) and we were caught in it; nobody was seriously criticising government policy before the crisis.  As the economy has failed to bounce back, this has become unsustainable; why are we having so much difficulty when other countries caught by the crisis are having an easier time?  Of course some try to say this is because of Coalition policies over the last year.  But almost all of the many critics of the Coalition policies accept that we were in a terrible mess in the first place.

So the critics shift to another target: Britain’s bankers.  These are an easy target, paying themselves handsomely while their organisations required government bailouts.  There is also a widespread conception that the bailouts cost a lot of money, and that this is one of the reasons that government debt is a problem.  Actually the government has largely got away with it, for which Gordon Brown and Alistair Darling deserve some credit (contrast the terrible hash that the Irish government has made).  A lot of government money was put at risk, yes, but the banks were charged for it, and the money lent will largely be repaid, and the guarantees not called on.  Where the bankers were culpable was in rampant lending, supporting excessive consumption and a property bubble.  But the lending was nothing like as reckless as in the US (or Ireland for that matter).  If the government had awakened to the idea that consumer lending needed restraint, something could have been done.  Let me be clear; the banks were reckless; we need to regulate them much better – but they were not the fundamental cause of the crisis.  We had a narrow escape.

Could the government have seen the vulnerability of the British economy?  There were not many prominent critics at the time, though Vince Cable was clear enough, for exactly the right reasons.  But it was a matter of undergraduate economics to see that economic policy was on an unsustainable path.  Literally.  As a second year economics undergraduate at UCL in early 2007 my macroeconomics lecturer, Professor Wendy Carlin, used the UK economy as a case study to illustrate her model for an open economy.  It was also used as an exam question.  Was the UK’s strong economic performance due to increasing economic efficiency or excess aggregate demand, she asked.  It was clearly the latter: the giveaways being the appreciating real exchange rate, and a large current account deficit (the economy as a whole consuming more than it was spending).

What should the government have done?  The first thing should have been to raise interest rates and tighten monetary policy much earlier.  Unfortunately this was genuinely difficult, because this was the Bank of England’s main target was inflation, and not the general standing of the monetary system. And the inflation rate seemed benign (thanks in large part to the overvalued pound).  The second thing would have been to regulate the banks harder, to restrain lending.  This was the FSA’s job, although the degree of independence of this agency is less strong.  Finally the government could have tightened fiscal policy to reduce the level of demand in the economy, through expenditure cuts or tax increases.  Nominally the government’s policy was to run a zero structural deficit, but it chose to fiddle with the statistics on the economic cycle so as to argue that it did not have to do anything.  The government was not egregiously profligate, as Coalition politicians like to suggest, but it was pushing the wrong way.

What comes over, above all, is a failure of leadership, especially from Gordon Brown, as a formidably powerful Chancellor of the Exchequer.  The tripartite arrangement for managing the financial system (between Treasury, Bank of England, and FSA) did not help, but it is very clear that if in doubt it was the Treasury’s job to lead.  They didn’t.  They could have leant on the FSA and Bank of England, as well as tightening fiscal policy directly.  But Mr Brown either refused to recognise the gravity of the situation, or his political courage failed him.  Given his constant level of denial about the seriousness of the crisis, I suspect it was mainly the former.  He could not face admitting that so much of economic achievement was unsustainable.  It is invidious to blame one man, when the hands of many were involved.  But Gordon Brown had the authority; there was enough evidence for him to act on; and he made things worse not better.  A career in the Treasury that had started so brilliantly ended catastrophically.

My next topic on the economy: is the Coalition economic policy making matters worse or better?

 

 

NHS reform – the politics is a smokescreen

Ever since the NHS was formed over 60 years ago, politicians have struggled to manage it.  Assorted ministers and policy wonks have dreamed up elegant reform plans, while the NHS’s insiders have undermined them in a bid to carry on much as before.  The NHS does change, but never quite along the path that the politicians have in mind.  That is as true now as ever.  The difference is that NHS management is promoting reform rather than resisting it; but they are going about it in their own way.  The fire and fury of the current political debate is mostly irrelevant.

I have already posted some thoughts on the NHS.  I considered the question of the timing of the reforms, alongside the £20bn cost-saving challenge posed by NHS Chief Executive Sir David Nicholson (referred to alternatively as “the Nicholson challenge” or “the QIPP*programme”).  My conclusion was that the main organisational damage has already been done, so we do not have much choice but to follow through.  I left aside the question of whether the reforms are wrong-headed.  I would like to consider this, before coming to an equally pragmatic conclusion.

What is being proposed?  A continuation of the big idea of the last 20 years or so: to create a purchaser/provider split, and to use this to introduce market mechanisms, under the banner of improving choice, to help ensure that the NHS is effective and efficient.  The problem that these reforms are supposed to solve is that the NHS is too dominated by hospitals, and the doctors who run them, who do not have enough incentive to change to meet new needs or to become more efficient.

In this latest incarnation, the purchaser element (now usually referred to as commissioners) of this set-up will be a combination of consortia of general practitioners (GPs), and an arms-length NHS Commissioning Board operating at national level (i.e. for England – the reforms don’t cover the other parts of the UK).  The intermediate commissioners under the current system, regional Strategic Health Authorities (SHAs) and district Primary Care Trusts (PCTs), are to be phased out.  On the provider side (i.e. the hospitals and other facilities), the idea is that all NHS facilities should be run by more or less independent Foundation Trusts, but that the commissioners will be allowed to secure services from “any qualified provider”, which will not be restricted to these trusts.

These reforms are a natural, if rather accelerated, continuation of the previous government’s NHS reforms.  Commissioning by GPs was already being piloted, and the idea of moving all hospitals to Foundation Trusts was the previous government’s idea too.  What is newer, and perhaps more radical, is the proposed regime of accountability that is being imposed on this.  Previously the NHS was run by the Secretary of State for Health, with very little restraint or accountability.  Now a complex framework of powers and accountabilities is being imposed, giving both parliament and local authorities a greater role.

The government argues that this is just evolutionary change.  But there has been vehement opposition from people who think that the new regime will end the NHS as we know it.  One problem is the commendable desire by the government to establish much of the framework in parliamentary law, rather than simply letting the minister rearrange things by fiat.  People now have the opportunity to project all their worst fears into the legislation on the basis that it does not specifically ban them.  In fact we are still being asked to trust ministers to do the right thing, only with more accountability.

Two lines of criticism that I can see have some kind of traction.  First is that the framework will open up the health market to competition law (and specifically European law) in the same way as for gas and electricity.  This means that the NHS trusts and the private sector would have to compete on a level playing field – and this might literally drive some NHS trusts out of business.  A lot of what NHS hospitals do is a natural monopoly (accident and emergency work, complex surgery, etc) , like the railways.  The fixed costs are so high that the market cannot sustain competition in most localities.  However, so the argument goes, these fixed costs also support activities where private sector competitors could undercut the NHS; if these are competed away then many hospitals would cease to be viable, and so the service on core activities would deteriorate.

Frankly I’m not stressed by this.  If a train wreck is on the way, it will be in very slow motion, giving time to take corrective action if need be.  More to the point, NHS professionals are masters at keeping the private sector at bay (except for NHS doctors doing private work on the side…), and they will only be seriously vulnerable in places were the service offered is ludicrously bad.  And as for European competition law, judging by its impact (not) on the French and German energy markets, there shouldn’t be anything that the politicians can’t handle.

The second criticism is more cogent.  It is that the rules for setting up GP commissioning consortia are a bit vague.  They could be set up in such a way that makes them very difficult to hold to account, or to act in partnership with other agencies.  For example, they may not be geographically coherent, cross local authority boundaries, and so on.  This does need some more thought – though again the worry is the direction reforms could take, rather than what is actually likely.

Personally, I don’t place a huge amount of faith in the purchaser/provider split and the marvels of choice anyway in this context.  There are two big problems: that the buyers (you and me) don’t know enough about what they are buying, and have to rely on intermediaries, whose incentives distort the picture.  The second is that so many providers are natural monopolies.  After decades of reform, the NHS does not remotely resemble a market economy.  It reminds me of a large company trying to introduce market-style rules for internal transactions; these systems never achieve as much as their proposers hope, since everything is trumped by politics in the end.  There have been two big achievements of the NHS reform process.  First is that hospitals are gradually being forced to be more efficient and accountable; this has mainly been achieved by good old-fashioned management, of which the “Nicholson Challenge” is but the latest example.  The second is that commissioning processes have forced NHS managers to address the question of what society actually needs, and then try to reorganise the service to meet these needs.  This last development is the more recent, and the the reorganisation of PCTs has interrupted it – but the new arrangements will probably be more effective in the long run.

The big prize to be won from the current reforms is hardly spoken of at all.  It is that GPs will start to come under the same sort scrutiny as hospitals have.  The consortia themselves will do some of this; the NHS Commissioning Board, which must authorise the consortia, will also be on the case.  The PCTs were supposed to be doing this, but were mostly pretty ineffectual.  The important point is that we should be in no hurry to authorise the consortia, to allow this scrutiny process to have real bite.  This seems to be exactly what Sir David Nicholson (who will chair the NHS Commissioning Board) has in mind.

Meanwhile the over-large number of PCTs has been reorganised into a more manageable number of “clusters”; these and the SHAs will no doubt live on as embodiments of the Commissioning Board.  The NHS will become much more centralised in the short term.  With some very sharp minds at the centre, including Sir David, this doesn’t have to end badly.  But the politcal arguments are mostly a smokescreen.

*QIPP stands for Quality, Innovation, Productivity, Prevention