In response to the Department of Health's call for ideas from public servants on how to cut costs and improve efficiency within the various public services, Red Dolphin has submitted a blueprint of 10 ideas, the implementation of which would unquestionably save money, improve efficiency and raise staff morale. It remains to be seen whether the government is courageous enough to implement it.
Dear Mr Cameron, Mr Clegg and Mr Lansley,
"More for Less": Ideas for cost savings and efficiency improvements in the NHS
1. The European Working Time Directive
Whilst no one would wish to see a return to the 'bad old days' of the 100-hour week and the tiredness-induced mistakes that this bore, the pendulum has swung too far the other way and opting out of the EWTD would allow junior doctors achieve decent amounts of training during their time whilst still capping the hours worked for safety reasons. After all, consultants are not subject to this constraint and for them it is currently entirely possible for one to be on call from Thursday morning until Monday afternoon these days and this is not illegal. Whilst that is not tolerable as a junior doctor we are currently in a situation where good specialist registrars deliberately fail their final year assessments in order to get a further year of training: more doctors does not equate to better doctors. A better training experience (the apprentice style is still the best) creates a higher quality of doctor. The New Labour tactic of throwing money at the problem was in fact counter-productive. So: train fewer doctors but train them more intensively thus saving salaries.
2. Study Leave Budgets
As in the airline industry it should be the responsibility of doctors to arrange and fund their own Continuing Professional Development, whether it be courses, meetings or sabbaticals. The £700 a year or so that is potentially spent on every doctor in the country could be withdrawn. With revalidation due to come on line in 2012 this is a good opportunity for the profession to demonstrate it's own professionalism and no longer rely on the public purse to pay for updating it.
3. Clinical Excellence Awards
Bonuses in the public sector should be all but unnecessary and this divisive set of awards should be dramatically pared down to reward only the most deserving. One criteria should be that the recipient does no private practice work. The negative effect that CEAs have on the profession far outweighs any incentivisation that they induce as the majority of consultants who do plenty of 'extra' work receive no points and feels doubly aggrieved when not awarded one in any given year. The exaggerated and even bogus claims that are made in the application rounds should make these an early target for cuts and, as they are pensionable, will make for significant savings. A national, independent panel including members from outside the profession should judge the very few remaining cases against stringent standards of merit and achievement.
4. Middle management
Partly, but not entirely borne of the era of New Labour targets, there are too many people engaged in meaningless exercises of counting what does not need to be counted - and furthermore not even understanding what it is they have counted due to a lack of understanding of the system. Great swathes can be cut through the reaches of 'assistant project managers' and similar to save millions at a stroke. Allowing clinicians more freedom to govern themselves - and this might include some more education in the history and running of the Health Service at medical school - will end their disenfranchisement of recent years and end the 'counting culture' that currently abounds.
Remember the adage that "not everything that can be counted counts, and not everything that counts can be counted."
5. Reduce generic working
Whilst the introduction of generic working - that is for work of a general nature to be performed by anyone within a particular department rather than a named individual - is useful for the reduction of waiting lists, the principle when applied too rigidly can be obstructive. Clinicians value the personal link and the ability of an individual consultant-secretary combination to prioritise and manage appointments is immeasurably valuable and more efficient than a rigid adherence to the generic principle. This would increase efficiency by reducing waste both in terms of unnecessary appointments being issued and the small 'team' understanding the particular abilities and limitations of any given service.
6. Budgets within the Internal Market
Whilst the concept of the internal market appears set to stay for now it must be recognised that the myriad of small, notional micro-budgets held within every department and managed almost in isolation creates a cottage industry of accountants and administrators who merely hamper the smooth running of a hospital or primary care facility. Internal 'purchasing' of services within a large hospital, for example, is meaningless as the is no competition (the idea behind the internal market) to drive any change. Meanwhile non-clinical managers push spreadsheets of inaccurate figures around the organisation, basing decisions on these data that affect clinical care. Whilst disciplined spending of an annual budget in any department is of course mandatory, clinicians should have more involvement in the process, it needs to be greatly simplified and far fewer people need to be involved in it's management.
7. Strategic Health Authorities
These leviathan organisations offer very little value for money. The majority of their budget is spent on education and this 70-80% could be devolved directly to the Deaneries, thus saving the 'middle man'. Whilst the role for Public Health is of course vital this should become a stand-alone speciality, especially as the SHAs add little or no strategic thinking to the process. The cut in personnel and sale of the resultant plush real estate currently given over to them would result in huge financial and efficiency gains for the NHS as a whole.
8. Postgraduate education
This aspect of medical life has become needlessly bloated over the last decade with courses existing for multiple unnecessary topics. As discussed in point 2 the profession needs to take responsibility for it's own clinical and non-clinical updating. The release of Trusts from the fear that every action needs accountability to the n-th degree would make unnecessary the many "compulsory" courses that are now the norm prior to undertaking any extra work. If indemnity from consequences could be assured in many areas then these box-ticking exercises could be usefully abolished with the consequent saving of salaries and gains in clinician productivity.
9. Cancer networks
Whilst the cancer multiple-disciplinary team (MDT) are an essential and irreversible innovation the bureaucracy to which they are currently answerable should be significantly slimmed down. The cancer networks as they currently exist are yet more circular middle management jobs the output of which serves more to obstruct than to help the frontline staff.
10. GP commissioning
Currently this is a highly complex process involving yet more accountants and middle managers and it need not be so. GPs are well placed to inform secondary care Trusts what services they need but again, infinitely dividing their notional budgets simply creates more administrative work rather than helping the process. Broad quotas and plans for when these are significantly exceeded or unreached, agreed by the relevant clinicians, are all that is necessary to avoid the current 'death by spreadsheet' system that obfuscates rather than clarifies the need for any given service.
Yours faithfully,
The Red Dolphin
Saturday, 26 June 2010
Monday, 21 June 2010
Common sense... 1 Theorists... 0
The announcement today of changes to the NHS Operating Framework including the scrapping or softening of many targets has breathed new hope into the clinical body, an organism that has been sorely tried by the last decade of over-management. Told time and again that we were not trusted to deliver a fair and efficient service by the then government such that we needed the yoke of these targets in order to perform, the resentment has grown and grown. As much time was given to ways of circumventing the more ridiculous diktats as was given over to useful innovation with the public purse the inevitable loser. Clinicians were left to battle with the unforeseen consequences of the targets and then blamed for them too.
Whilst the patients' views are clearly valuable to any health planning exercise they lack both the knowledge and the detachment to be able to offer the final say, whereas the clinicians that work day in, day out at the medical coalface understand the issues, the strengths and limitations of the service and - contrary to New Labour's rhetoric - care deeply about the people they serve. There are rotten apples in any basket, but not many in this one.
So now, rather than introducing a headline-grabbing target of 4-hour A&E waiting time and not know, care or worry about the patients who were unnecessarily moved onto an inappropriate ward to avoid breaching the target, now we can concentrate on making parameters that are meaningful, achievable yet challenging and above all, practical.
Move over theorists, common sense has arrived.
Whilst the patients' views are clearly valuable to any health planning exercise they lack both the knowledge and the detachment to be able to offer the final say, whereas the clinicians that work day in, day out at the medical coalface understand the issues, the strengths and limitations of the service and - contrary to New Labour's rhetoric - care deeply about the people they serve. There are rotten apples in any basket, but not many in this one.
So now, rather than introducing a headline-grabbing target of 4-hour A&E waiting time and not know, care or worry about the patients who were unnecessarily moved onto an inappropriate ward to avoid breaching the target, now we can concentrate on making parameters that are meaningful, achievable yet challenging and above all, practical.
Move over theorists, common sense has arrived.
Monday, 7 June 2010
Take a 180 degree look around
On my way to London on the train this morning I was momentarily confused by a double illusion of motion and stasis. To explain - the train was stationary at a platform alongside another when this second one moved off giving the familiar sensation that my own train was pulling off. However, this was not mirrored by the expected simultaneous sensation movement that ought to come with this and for a few moments I was disorientated, not to say actually quite dizzy. Only when I looked through the opposite window to see a branch of a well known coffee shop reassuringly static On the platform did my equilibrium return as my brain was able to make sense of the conflicting messages that had previously been passed to it.
And this got me thinking as we all relentlessly plunge into the daily routine, having and giving little time for reflection on even the most major issues that affect us in the longer term. The reason I was on the train in the first place was to attend a conference at The King's Fund on the implications of the election result on the NHS. Speakers from both the Fund and outside outlined their views on the times ahead - but in truth of course nobody knew anything for sure. There was a fair degree of consensus that the pledge to cut administration would be enforced somehow but, understandably, there was anxiety in the air in this management heavy audience. Many views on how to improve efficiency and the same for achieving quality in commissioning but surprisingly nothing about the proposed independent board. Much food for thought but little to aid the digestion, one might say.
And so I thought about my train analogy: perhaps we need to look in completely the opposite direction to achieve some clarity of thought. Rather than try and modify the system we currently have we should rethink it root and branch. The internal market, in place for nearly two decades, has not brought about the revolutionary change that was expected by the introduction of free market principles into a closed market. It should not feature as a part of our future. Rather, let us focus on the patient's journey along disease paths and fund these accordingly using well validated incidence and cost data and thus end the artificial division between primary and secondary care, surgeon and physician, acute and chronic care. Like it or not, the next generation of doctors and nurses will need to be well versed in the nuts and bolts of how the service is run and funded. This is not unique and applies in other countries so we should not be afraid of a slimmer, more accountable and transparent service that has patients at it's heart and healthcare workers as the drivers for change. Those who work within the service are best placed to advise on the way to change it for the better. This way we can achieve more agreement on what constitutes best practice and how to roll it out across the country. And the management infrastructure that has manifestly not succeeded in this to date can hence be drastically slimmed down.
If we miss this opportunity to revolutionize the way the NHS functions we may not have the chance again as then either the service will fail due to lack (or waste) of funding, or survive in some fiscally healthier future climate that allows this wastage to go unchecked again. We should not put ourselves in the position of seeing the train of opportunity leave without us being on it.
"The train now leaving ...." are not words we want to hear from the platform; rather we should seek to shout: "The old stations are behind us" as we travel down a new track.
And this got me thinking as we all relentlessly plunge into the daily routine, having and giving little time for reflection on even the most major issues that affect us in the longer term. The reason I was on the train in the first place was to attend a conference at The King's Fund on the implications of the election result on the NHS. Speakers from both the Fund and outside outlined their views on the times ahead - but in truth of course nobody knew anything for sure. There was a fair degree of consensus that the pledge to cut administration would be enforced somehow but, understandably, there was anxiety in the air in this management heavy audience. Many views on how to improve efficiency and the same for achieving quality in commissioning but surprisingly nothing about the proposed independent board. Much food for thought but little to aid the digestion, one might say.
And so I thought about my train analogy: perhaps we need to look in completely the opposite direction to achieve some clarity of thought. Rather than try and modify the system we currently have we should rethink it root and branch. The internal market, in place for nearly two decades, has not brought about the revolutionary change that was expected by the introduction of free market principles into a closed market. It should not feature as a part of our future. Rather, let us focus on the patient's journey along disease paths and fund these accordingly using well validated incidence and cost data and thus end the artificial division between primary and secondary care, surgeon and physician, acute and chronic care. Like it or not, the next generation of doctors and nurses will need to be well versed in the nuts and bolts of how the service is run and funded. This is not unique and applies in other countries so we should not be afraid of a slimmer, more accountable and transparent service that has patients at it's heart and healthcare workers as the drivers for change. Those who work within the service are best placed to advise on the way to change it for the better. This way we can achieve more agreement on what constitutes best practice and how to roll it out across the country. And the management infrastructure that has manifestly not succeeded in this to date can hence be drastically slimmed down.
If we miss this opportunity to revolutionize the way the NHS functions we may not have the chance again as then either the service will fail due to lack (or waste) of funding, or survive in some fiscally healthier future climate that allows this wastage to go unchecked again. We should not put ourselves in the position of seeing the train of opportunity leave without us being on it.
"The train now leaving ...." are not words we want to hear from the platform; rather we should seek to shout: "The old stations are behind us" as we travel down a new track.
Sunday, 6 June 2010
The past is a foreign country
My daughter came home from nursery a couple of weeks ago singing a new song that she had learnt that day. After the initial parental pride and pleasure at discovering that she had memorized it so quickly it made me think of the healthcare that she might expect in her dotage. The lyrics are worth repeating here - you will see why.
Miss Polly had a dolly that was sick, sick, sick
So she called for the doctor to come quick, quick, quick
The doctor came with his bag and his hat
And he knocked on the door with a rat-a-tat-tat.
He looked at the dolly and he shook his head
And he said "Miss Polly, put her straight to bed."
He wrote on a paper for a pill, pill, pill
"I'll be back in the morning - yes I will, will, will.
Doubtless you can already see where this is going. The utopian vision presented to the children here is of a rapid resonse personal service to the home - note the use of the definite article 'the' doctor: not any old doctor - her own family doctor. The traditional Victorian image of the frock coated physician persists as does the diminishing skill of clinical acumen - the ability to recognise sick patients is now no longer an assumed, not to say real part of the modern doctor that juniors are sent on compulsory courses to learn this vital art.
The part about treatment at home fits in well with the modern notions of healthcare so that is one area of which the old DoH doyens would approve but a paper prescription? Hardly the Connecting for Health ePrescribing on an electronic patient record, is it? As for the idea of continuity and follow up that is very rare these days. Shift patterns and the diminishing professionalism borne of clock-watching have seen to that.
So whilst we still wait to see what plans the coalition government has for our future and hope against hope that the top-down micromanagement goes with the legions of unnecessary administrators, I propose a modern version of the same song.
Miss Polly had a dolly that was sick, sick, sick
So she called the approved emergency number for out of hours consultations
A locum said: "Can you come to the local walk-in centre?"
Where he sat with his arms bare below the elbow and no tie.
He entered the dolly's vital signs into his computer and said:
"She doesn't fulfil the criteria for antibiotics so give her Calpol instead",
"I'll arrange for one of the nurses to ring you up in the morning to see if she is any better."
Not all change is progress.
Miss Polly had a dolly that was sick, sick, sick
So she called for the doctor to come quick, quick, quick
The doctor came with his bag and his hat
And he knocked on the door with a rat-a-tat-tat.
He looked at the dolly and he shook his head
And he said "Miss Polly, put her straight to bed."
He wrote on a paper for a pill, pill, pill
"I'll be back in the morning - yes I will, will, will.
Doubtless you can already see where this is going. The utopian vision presented to the children here is of a rapid resonse personal service to the home - note the use of the definite article 'the' doctor: not any old doctor - her own family doctor. The traditional Victorian image of the frock coated physician persists as does the diminishing skill of clinical acumen - the ability to recognise sick patients is now no longer an assumed, not to say real part of the modern doctor that juniors are sent on compulsory courses to learn this vital art.
The part about treatment at home fits in well with the modern notions of healthcare so that is one area of which the old DoH doyens would approve but a paper prescription? Hardly the Connecting for Health ePrescribing on an electronic patient record, is it? As for the idea of continuity and follow up that is very rare these days. Shift patterns and the diminishing professionalism borne of clock-watching have seen to that.
So whilst we still wait to see what plans the coalition government has for our future and hope against hope that the top-down micromanagement goes with the legions of unnecessary administrators, I propose a modern version of the same song.
Miss Polly had a dolly that was sick, sick, sick
So she called the approved emergency number for out of hours consultations
A locum said: "Can you come to the local walk-in centre?"
Where he sat with his arms bare below the elbow and no tie.
He entered the dolly's vital signs into his computer and said:
"She doesn't fulfil the criteria for antibiotics so give her Calpol instead",
"I'll arrange for one of the nurses to ring you up in the morning to see if she is any better."
Not all change is progress.
Monday, 31 May 2010
Sense with Sensibilty
The departure of David Laws this weekend is more than a sadness for the coalition and a blow to the Treasury. As the man responsible for the cuts that we shall all have to endure the NHS looked to him to ensure equity and fairness. Acutely aware of the promise to increase real-time funding over the lifetime of this parliament we recognise the need to spend wisely what we have and the privileged position that we hold in public service life. Giving us this gift during a time of financial crisis requires delicate and sound judgement in the management of all other areas of the economy.
All the more important therefore that the man overseeing these spending rearrangements is of the very highest quality and seeing David Laws disappear into the political shadowlands in the precise opposite of what is necessary. The exposure of a claim that may or may not be at the limits of the definition of the word 'partner' coupled with the Daily Telegraph's shameful homophobia does not begin to justify this ousting.
The Red Dolphin therefore calls upon the British public to demand the reinstatement of the man 'put on this earth to sort out the economy' (and preferably simultaneously shun the DT). In this 'new politics' era where we, the populace, have a voice let us call as one for both national benefit and common sense.
Or in the modern tongue: #bringbacklaws.
All the more important therefore that the man overseeing these spending rearrangements is of the very highest quality and seeing David Laws disappear into the political shadowlands in the precise opposite of what is necessary. The exposure of a claim that may or may not be at the limits of the definition of the word 'partner' coupled with the Daily Telegraph's shameful homophobia does not begin to justify this ousting.
The Red Dolphin therefore calls upon the British public to demand the reinstatement of the man 'put on this earth to sort out the economy' (and preferably simultaneously shun the DT). In this 'new politics' era where we, the populace, have a voice let us call as one for both national benefit and common sense.
Or in the modern tongue: #bringbacklaws.
Friday, 28 May 2010
It's the people, stupid
Well, the noises coming from the Department of Health are encouraging. Increases in real time NHS funding, cutting administrative waste, reducing manager numbers, devolving power to local levels to stop the top-down micromanagement culture so prevalent these past years. Not much detail has emerged yet to put the flesh on these ostensibly attractive bones but it is early days.
The potentially most exciting announcement is the creation of an independent NHS board outside political control. How exactly this might work will be the cause of much discussion, debate and disagreement in the weeks to come but the priciple is sound and has long been advocated by this author. The difficulties lie in ensuring non-political appointments, equitable distribution of power between it and government - an impotent board would be mere window dressing but an entirely unaccountable one would soon become corrupt - and above all, the sticky question of 'Who guards the guards?'. Many will be left unhappy at the end of this process but I believe it could be a large step in the right direction.
My hope is that the new board will have the power, foresight and gumption to tackle the very way that money flows through the NHS. The internal market, created in 1991, revamped in 2002 and seemingly beloved of both Labour and the Conservatives before them is inherently flawed. Applying free market business principles to an essentially closed market does not make sense. At no time was this better highlighted than Labour's disastrous attempt to introduce Independent Sector Treatment Centres (ISTCs) into the equation to generate competition with the NHS. As they cashed in on non-performance related start-up and subsequent payments, generous tariffs and the ability to cherry-pick the easiest, low risk cases with no responsibility for any ensuing complications the rest of the medical world gazed in wonder as to how this could possibly have ever been thought to be a good idea. Sure enough, the impact on quality was minimal, the effect on morale devastating and there is now good evidence, to take one area at random, that their introduction continues to jeopardise training as junior doctors see the 'easy' cases where they traditionally learnt their craft, vanish to the private sector.
But the biggest reason that the internal market failed is the human factor. In a truly free market organisations are free to choose the best people for the job and can replace them if they fail. Whilst this holds true for the medical and nursing staff of the NHS, it most manifestly does not for the managerial cadre as the best of them naturally gravitate to the private sector with its higher pay and bonuses and the choice for the public sector is akin to picking the wheezy fat boy for one's sports team at school when all the athletic types have already been chosen. Of course there are exceptions and there is a cohort of managers who both have talent and value service above personal gain but those with this laubable combination of skills and views are the distinct minority.
The new NHS must not just be a slimmed down version of today's but there must be a
sea-change in the approach to staff recruitment and retention. Even the name - 'Human Resources' - suggests a depersonalisation of the subject since the happier days of 'Medical Staffing'.
It is the people that make the organisation and the knowledge and skill-base that exists within the NHS is unparalleled and should be allowed far more freedom to provide the service. Management teams drawn far more from the ranks of clinical staff will be able to run a much more efficient service as they understand the issues rather better than a 'professional health service management trainee'. And they will know that the artifical constraints imposed by the internal market, the arbitrary division of primary and secondary care, makes no sense. Given this power to change I predict that the service will transform out of all recognition leaving the politicians little more to do than claim the credit for it.
But first they need to remember: it's not principally about the economy. It's the people, stupid.
The potentially most exciting announcement is the creation of an independent NHS board outside political control. How exactly this might work will be the cause of much discussion, debate and disagreement in the weeks to come but the priciple is sound and has long been advocated by this author. The difficulties lie in ensuring non-political appointments, equitable distribution of power between it and government - an impotent board would be mere window dressing but an entirely unaccountable one would soon become corrupt - and above all, the sticky question of 'Who guards the guards?'. Many will be left unhappy at the end of this process but I believe it could be a large step in the right direction.
My hope is that the new board will have the power, foresight and gumption to tackle the very way that money flows through the NHS. The internal market, created in 1991, revamped in 2002 and seemingly beloved of both Labour and the Conservatives before them is inherently flawed. Applying free market business principles to an essentially closed market does not make sense. At no time was this better highlighted than Labour's disastrous attempt to introduce Independent Sector Treatment Centres (ISTCs) into the equation to generate competition with the NHS. As they cashed in on non-performance related start-up and subsequent payments, generous tariffs and the ability to cherry-pick the easiest, low risk cases with no responsibility for any ensuing complications the rest of the medical world gazed in wonder as to how this could possibly have ever been thought to be a good idea. Sure enough, the impact on quality was minimal, the effect on morale devastating and there is now good evidence, to take one area at random, that their introduction continues to jeopardise training as junior doctors see the 'easy' cases where they traditionally learnt their craft, vanish to the private sector.
But the biggest reason that the internal market failed is the human factor. In a truly free market organisations are free to choose the best people for the job and can replace them if they fail. Whilst this holds true for the medical and nursing staff of the NHS, it most manifestly does not for the managerial cadre as the best of them naturally gravitate to the private sector with its higher pay and bonuses and the choice for the public sector is akin to picking the wheezy fat boy for one's sports team at school when all the athletic types have already been chosen. Of course there are exceptions and there is a cohort of managers who both have talent and value service above personal gain but those with this laubable combination of skills and views are the distinct minority.
The new NHS must not just be a slimmed down version of today's but there must be a
sea-change in the approach to staff recruitment and retention. Even the name - 'Human Resources' - suggests a depersonalisation of the subject since the happier days of 'Medical Staffing'.
It is the people that make the organisation and the knowledge and skill-base that exists within the NHS is unparalleled and should be allowed far more freedom to provide the service. Management teams drawn far more from the ranks of clinical staff will be able to run a much more efficient service as they understand the issues rather better than a 'professional health service management trainee'. And they will know that the artifical constraints imposed by the internal market, the arbitrary division of primary and secondary care, makes no sense. Given this power to change I predict that the service will transform out of all recognition leaving the politicians little more to do than claim the credit for it.
But first they need to remember: it's not principally about the economy. It's the people, stupid.
Thursday, 20 May 2010
Opportunity Lost or Paradise Postponed?
The Coalition's much vaunted Programme for Government has arrived and the direction of our next five years is fixed. I suppose the rumours were always too good to be true. The idea that centrally imposed government targets would cease and that Strategic Health Authorities would be abolished clearly sounded good on paper but in the cold light of day did not survive the political process. What has been announced is certainly a change - much of it for good - but is diluted compared with the promised land.
The guarantee of real term increases in NHS spending is of course welcome but, if we have learnt one thing from the last 13 years, it is that spending without proper guidance is shackling. Cutting administration and quangos is also to be encouraged; giving frontline staff more control of their working environment sounds good but many of the statements are somewhat vague - some might say suitably vague at this early stage - and the devil may yet emerge with the details. But overall the document does provide some grounds for cheer and so one can only hope that it heralds bolder and more liberating reforms further down the line. Great oaks from little acorns grow.
I grow tired of hearing that 'the public voted for a coalition' as though the public is one large sentient being. Some people may have cast their vote in the hope of electing one or other party; others may have voted tacically to keep out their least favourite; others may have indeed voted in the hope that a hung parliament would result. We shall never know. But one thing is for certain and that is that we, the public, did not have a pre-election mass huddle to determine who would vote for whom and where. The result is a statistical one borne of millions of votes and, whilst the numbers may vary, is precisely what would happen if we adopt PR. Coalitions would be the norm. So the fact that this document represents much watering down and postponement of the tough decisions pending 'commissions' should not be too much of a surprise. If we reform our voting process it will be a template for future similar publications - every five years. Our duty for now is to try and make it work.
Therefore we should not lose heart entirely but remain optimistic about the intentions of our new coalition - or rather not the intentions but their (to use government's own term) ability to deliver. Bold moves inevitably lead to polarised responses from the media and public alike and in the current vacuum of political certainty that accompanies the first coalition since the war, no one can accurately predict which way the mood pendulum will swing. Better then to introduce measures piecemeal and buffer any negative reactions than to risk it all on the first hand. This is not a Miltonesque tour de force that was published today. But let us hope that it heralds a paradise to be regained.
The guarantee of real term increases in NHS spending is of course welcome but, if we have learnt one thing from the last 13 years, it is that spending without proper guidance is shackling. Cutting administration and quangos is also to be encouraged; giving frontline staff more control of their working environment sounds good but many of the statements are somewhat vague - some might say suitably vague at this early stage - and the devil may yet emerge with the details. But overall the document does provide some grounds for cheer and so one can only hope that it heralds bolder and more liberating reforms further down the line. Great oaks from little acorns grow.
I grow tired of hearing that 'the public voted for a coalition' as though the public is one large sentient being. Some people may have cast their vote in the hope of electing one or other party; others may have voted tacically to keep out their least favourite; others may have indeed voted in the hope that a hung parliament would result. We shall never know. But one thing is for certain and that is that we, the public, did not have a pre-election mass huddle to determine who would vote for whom and where. The result is a statistical one borne of millions of votes and, whilst the numbers may vary, is precisely what would happen if we adopt PR. Coalitions would be the norm. So the fact that this document represents much watering down and postponement of the tough decisions pending 'commissions' should not be too much of a surprise. If we reform our voting process it will be a template for future similar publications - every five years. Our duty for now is to try and make it work.
Therefore we should not lose heart entirely but remain optimistic about the intentions of our new coalition - or rather not the intentions but their (to use government's own term) ability to deliver. Bold moves inevitably lead to polarised responses from the media and public alike and in the current vacuum of political certainty that accompanies the first coalition since the war, no one can accurately predict which way the mood pendulum will swing. Better then to introduce measures piecemeal and buffer any negative reactions than to risk it all on the first hand. This is not a Miltonesque tour de force that was published today. But let us hope that it heralds a paradise to be regained.
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