This piece is another about change and how we can prepare ourselves and society for it in such a way as to make people feel that the inevitable burdens imposed by it are being fairly shared by one and all. However one the biggest challenges during such times will always come from those with a vested interest in the status quo because and inevitably, rather than seeing themselves as the Luddite obstructors they are, they will portray themselves as “up holding standards” for society in whatever field they happen to be from.
Britain is an evolutionary rather than a revolutionary country but never the less, major changes have too often only been accepted by our society only as the result of calamities.
Votes for Women
Whilst in highlighting the issue of votes for women was crucial in bringing the topic into the public consciousness of the day, I would argue that it wasn’t the suffragettes that won women the vote it was the slaughter on the Western Front in WWI that did that.
Between 1914 and 1918 the British Empire lost killed in action 953,104 of which 744,000 were British. By the time the war was over, there were many women, numbering in the tens of thousands who were ‘heads of households’ simply by dint of being widowed, they had to be given a ‘voice’. That women would have got the vote anyway and in due course, I have no doubt but in the end it was the tragedy of WWI that accelerated the whole process.
The question is, can we by talking through issues publicly avoid having to wait on some kind of implosion before we embrace the changes we need to make ? In my previous post on change I focused in on electric and hybrid vehicles but less as regards the technology and more their impact on the tax gathering of the UK Government as the cash cow of the internal combustion engine disappears into industrial history. It is this principle that people need to grasp because it is no longer a case of replacing one widget with a newer more sexy widget, the digital economy may well abolish widgets altogether because they are redundant and that will have all kinds of other impacts up and down the food chain.
As I move past this ‘introduction’ allow me to finish with an idea that I will return to later but an idea that ties in with the whole idea of the enfranchisement of the masses rather than just women. For the ruling elite of the day, the idea of giving the vote to the great unwashed must have seemed dreadful, to surrender political power and the ability to order the affairs of the nation to suit the pockets and tastes of yourself and people “like you”lost forever, horrible ! But what if today we have another different but parallel event that will be as far reaching but this time not being control of the political agenda but control of wealth creation.
The wealthy today are in the same position as the ruling classes were in their day, in total control of their “power”, now suppose that ‘power’ has to be shared, the power of course being the profits from business ?
What I mean by “vested interests” is simply the people who will see the current situation as to their personal advantage, generally economically and who will therefore resist change quite strongly. A good example of this concerns the housing crisis that we face whereby young people have been totally priced out of the market because a shortage of supply leads to ever increasing price rises. So is there a solution ? Yes obviously, build more houses but what are the obstacles to doing so ?
The problem is twofold, existing house owners like the price increases because they are already on the property ladder and builders don’t want to build too quickly because they want to maximise their profits on what properties they build. In both cases a shortage of property to buy suits them both and neither will give up what they see as their personal advantages but their vice like grip needs to be broken for the sake of greater equality.
The solution is obviously to build hundreds of thousands of new homes but as the ‘free market’ in an economy of stagnant wages, can’t meet the need, a third party needs to step in and that is the Government through a massive build program. However, rather than a traditional program of public housing complete with ‘life tenancies’, the program might be aimed at providing affordable rented property for the young and single rather than families. Tenancies would be short term, rolling and accompanied by suitable covenants governing behaviour towards the property and neighbours, enforceable by eviction if necessary.
As land is the main issue, you might consider legislation that allows the government to impose a 20 year lease on the owners of suitable land which is lying fallow, the landlord gets a ground rent and possession of their land at the end of the term. The housing units should be factory made units completely fitted, ‘plug in’ modular and capable of being renovated and/or recycled. Teams and systems would need to be developed for preparing sites for connecting modules to mains services so that whole sites once prepared could be erected, tested and occupied within weeks. One might consider making part of the rent charged a compulsory savings element so that tenants build up a housing savings account to be used towards a future house deposit.
Now the above is just a rough pen sketch but the point that I’m making is that trying to manipulate the existing market and market mechanisms is pretty pointless, the need is to think more radically. The objective is simple, by swamping whole areas with affordable rented housing you take the pressure off the young and by taking lots of them out of the private rental market even in cities like London, put downward pressure on the rents charged on rented properties and probably house prices too.
The NHS as a Problem Area
The NHS because of its obvious ’emotional’ connections with health and eventually dying is a highly emotive area and as far as allocating spending and resources to it, one where the government of the day can never win. The expectations people have of this service, hyped out of all proportion by politicians especially at election times, is frankly ridiculous and as far as budgets are concerned, it is a bottomless bucket without any sides, no matter what you throw at it, it will never be enough and users will never be satisfied.
When the NHS started in 1948, the UK had a population of just over 50 million and the budget in today’s terms was £9 Billion pa. Today the NHS is devolved so that England which has a population of 54 million has an NHS budget of £109 Billion or just over x12 the original amount for the whole of the UK back in 1948.
Whilst there is obviously lots more money the pressure on the NHS is unrelenting and more and more money is demanded but in truth, it cannot be the ‘answer’. We know the factors that are stressing the situation, people live a lot longer but with ever more complex health conditions, once in hospital and ready to be discharged, they often can’t be safely because they live alone or need specialist support to return home. Last Winter without there being a flu epidemic, Hospital A&Es were overrun by a 16% increase in visits largely caused by a shortage of local GP appointments. Many GP practices cannot recruit GPs for love nor money and many existing GPs want to retire and as GPs are the front line of the NHS, none of this is good news.
So this is where we are, just how do we start to solve it all ? It seems obvious to me that all the ‘solutions’ being talked about which inevitably mean more money are totally misguided in that people are thinking about solving today’s problems at some time in the future, whether they realise this or not. What they are not taking into account is that the ‘future’ will bring with it its own set of issues and problems which will need to be solved and are likely to be different from todays. Put another way, if we want a health service that can adapt and cope to the inevitability of change, we need to adopt a radically different approach.
Given that the NHS is the fifth largest employer in the World with NHS England employing 1.2 million people, there are obviously very many different issues to be tackled but for the purposes of this “thought piece” I will focus on medical staff and specifically doctors so we will start with a few key numbers concerning the time it takes to train them.
- They start with Medical School which lasts between 4-7 years
- This is followed by Foundation School which is another 2 years
- This is followed by selecting a speciality.
- For a GP this is another 3-4 years
- Other specialities range from 5-8 years
From this we can say that roughly it takes a decade to ‘build one doctor’ at an average cost to the student and the taxpayer the latter of whom carries the biggest part of this cost of £230,000 each copy which admittedly palls into insignificance compared to students in the USA where a personal debt of around $230,000 is not uncommon.
Solving the Problem
So let us suppose for the moment that a shortage of doctors is the main issue to be resolved, it won’t be of course but let’s say it is. In the short term you can ‘bribe’ current and about to finally qualify doctors by offering over 5 years, writing off all their student loans providing they work in the NHS, where you want them to be, loans being written off at 20% pa for each year completed. Now whilst this may appeal to some, by itself it won’t solve the problem so other measures would be needed too and particularly with regard to GPs.
The GPs are the front line so reinforcing them so that more patients are ‘sieved’ at an earlier stage, can go a long way to improving the service that hospitals can provide to their local communities so what are the possible barriers ?
The first one is that GPs are private practices, there are ‘Partners’ in the business which derives the majority of its income from the NHS. As the practice may well own physical property, in order to share in the ‘profits’ a doctor would have to buy into the partnership which probably means them raising the capital required via a personal loan. Their aim in the longer term being that in due course and as they reach retirement age, they can sell their share in the partnership thus generating additional capital If you don’t go down this route, then your job would be as a salaried doctor or, employee of the practice which whilst that comes with a good salary, doesn’t come with longer term capital generating opportunities.
Now whilst there would be some opposition from existing practices, in some geographical areas where shortages are worse, it might make sense for the local Health Care Authority to fund setting up GP practices and equipping them with whatever facilities make sense for that local area. The capital cost of this would be recouped over time by the local health authority but not over aggressively because you need to staff it fully. The concept might be that all employees from receptionists upwards participate in profit sharing whilst employed through bonuses paid annually on top of their basic salary.
Probably as another incentive, the structure of the working week could be changed for ALL medical staff both nurses and doctors so that they work four days in the GP Practice and then one day a week is either training/or broadening their skills through working in the local hospital or care system in an unpaid capacity. By an ‘unpaid capacity’ I mean to the hospital or other facility where they have a placement, they are in fact already being paid through the practice. The objective here is to ensure maximum reward for their service in the practice whilst they work there but also to keep their skills current in an ever changing world.
All the above are really band aids to the current position and situation, they are not solutions going forward because those (solutions), will use the usual range of tools to get major improvements to streamline the whole system. In broad terms this means that more but less qualified resources backed up by technology are placed in the immediate front line to sieve and sort patients into a priority system that effortlessly feeds the right patients through to the right level of care and clinical expertise they may need.
The obvious symptoms of such a system would be that patients would not expect to see a fully qualified doctor on their first visit to their GP’s surgery, they would expect to see a well qualified technical nurse who would go through their symptoms with them, automatically run a series of tests so that results could be passed on up the ‘food chain’ and decisions taken about next steps that are relevant to that particular patient.
Logically and whilst there will be a case for continuing the current system for growing new doctors, there also needs to be a parallel but totally different path that people could follow which does away with the differentiation between ‘doctors and nurses’, a from the ground up, training for a medical career. We need to get more medical staff qualified to a useful level faster, whether they start out as qualifying first as para medics and progress through practice nurse to nurse practitioner and from there study whilst working to qualify as a doctor. Taking 10 years to train one doctor who may then decide to emigrate or only work part time is poor value for money to society but it must also be a bit of a gut grinding marathon for the person taking up the profession too.
Not everybody who starts down this path will go all the way through the process to finally qualify as a doctor, many will stop at a level where they are most happy but two things will come out of this, an increase in the numbers of useful medical staff available plus the acceptance that in this as in most future careers, you have to accept life long study to keep your skills current and to enjoy a progressively improving income.
I do not claim in the above to have raised any startling new ideas but my aim was to point out that we need to start thinking outside of the box an awful lot more than currently seems the case if we are to rise to the challenges of tomorrow. It must also be obvious that we cannot rely on our political classes to generate new ideas, their personal horizons are only 5 years ahead to the next election at the beginning of each new Parliament so long term thinking is not their forte. If we want long term thinking then it is we the electors/citizens/people who are interested in the outcomes that need to set the pace and not beholden to any existing establishment group.
At the beginning of this piece I touched on a parallel between giving people the vote and profit sharing so I will finish with that. Although it might seem an odd thing to propose, if capitalism is to survive and prosper in the future decades, it may well only be possible by doing genuine profit sharing schemes with its workforce and I don’t mean some niggardly 5%, more like one third (33.3%) of pre-tax profits being paid as an annual bonus to the people who work within a business. Also this should be done on a very flat scale too from the lowest to the highest paid, there should be no “fat cat bonuses” for company directors.
Just like giving people the vote, society needs to share the wealth through rewarding personal labour rather than just by tinkering with tax bands and welfare benefits so that employers are bribed to create low paid jobs which are then topped up with State Benefits.