Three political shows
Three new podcast episodes I’ve produced that are out this week or coming soon:
New Statesman’s New Times: interview with the author of their cover story, ‘The closing of the liberal mind’;
A Beginner’s Guide to the Labour Party: Paul Mason joins regular hosts Holly Rigby and Jeremy Gilbert to discuss what new members should do now – out next week;
First episode of Really Take Control, a six-part miniseries for the New Economics Foundation: 'Take back control’ has been the slogan of the year. But what does it mean? Who’s got control now? And how can we create a new economy where people can really take control of their lives?
The NHS may be struggling to meet even relaxed cancer targets
This piece first appeared on Macmillan Cancer Support’s policy blog
Photo credit: Jordiet on Flickr
The NHS in England has now failed to meet a vital cancer target in all but one of the past 29 months — and on the latest evidence, it is struggling to meet even the relaxed targets set by NHS Improvement this July.
Recognising the problem in hitting the national target to treat 85% of patients within 62 days of an urgent GP referral, NHS Improvement put the previous system of fines on hold. Instead, most trusts now have an ‘improvement trajectory’ to meet, tied to a bit of extra money from a ‘sustainability and transformation fund’. Out with the stick, in with the carrot.
Uphill battle
It’s too early to say whether that approach will work in the medium term. But what we do know is that NHS Improvement appears to have a bigger challenge on its hands than it might have thought.
Here at Macmillan, we’ve been comparing actual performance against this target with the ‘improvement trajectories’ for the first quarter of this new system — July 2016 to September 2016 (the most recent stats available).
The actual picture differs in two important ways from what NHS Improvement wanted to happen by this point:
Many more trusts failed to meet the national target than NHS Improvement expected. By this point, just over 20% of trusts were expected to be missing the national target, leading into a period of recovery over the winter. Instead, it was more like half in July, August and September.
We may be seeing a divergence among trusts, between those persistently missing the target by a wide margin, and those meeting it by a comfortable margin. Such a wide divergence has implications for the way improvement funds are allocated.
Phantom carrot
Previously, trusts were fined for missing these targets. But since July, each individual trust can be rewarded for staying on their improvement trajectory with a pay-out from the £1.8bn Sustainability & Transformation Fund. 5% of that fund (or about £90m) is linked to this cancer target.
The idea is that rather than taking money away from struggling trusts, they should be helped to get back on track — a carrot rather than a stick — and between July 2016 and March 2017, much of the country is supposed to have recovered.
But according to our analysis, more than half of trusts (56%) could be at risk of missing out on this money, at least for the most recent quarter.
The rules go like this: in Q2 of 2016/17 (July to September), trusts need to be within one percentage point of their trajectory to get the pay-out. This then ratchets up to half a percentage point in Q3, until the ‘tolerance’ disappears entirely in Q4.
However, fewer than half (44%) of trusts were near enough to their improvement trajectories from July to September to qualify. Our estimate of the amount of money that might be withheld from these trusts during Q2 puts the figure at around £12.7m, though it’s hard to know for sure.
Reality check
It is too early to say whether this picture will improve as we move further into the winter. Early signs appear to be that the NHS is struggling even to meet relaxed targets. And perhaps more worrying is that these targets are being missed by so wide a margin that many trusts could continue to miss out on the money they need to improve, trapping them in a cycle of missed targets.
Macmillan will continue to speak out on behalf of the thousands of people who continue to wait too long to start treatment. We’d encourage NHS Improvement to keep a close eye not only on the targets, but also on whether its system for supporting trusts to get back on track is working.
With thanks to Samuel Jones in Macmillan’s Evidence department for help with data analysis
Notes
1) Not all trusts have ‘performance trajectories’ in NHS Improvement’s new system. According to a document published by NHS Improvement in July 2016, trusts that had not accepted a financial ‘control total’ were excluded, and at the time of the document’s publication trajectories were subject to change due while they waited for regional sign-off. So for the purposes of this post, and its charts and tables, we only looked at the 133 trusts that had trajectories set for this period.
2) A couple of points on our estimate of the money that might be withheld from trusts: firstly, we only included trusts that had performance trajectories in place and saw at least 5 patients in any given month. Secondly, we estimated the withheld funds as follows: 5% of the Sustainability and Transformation Fund is linked to the performance trajectories for the 62-day cancer target. 5% of £1.8bn = £90m. Assuming this money is spread equally over the four quarters of the year, the amount linked to this target between July-September = £22.5m. We estimate that 56.4% of trusts missed their trajectories by >1% for the most recently reported quarter. 56.4% of £22.5m = £12.7m. If you think we’ve estimated this incorrectly, please do let us know.
The New Statesman’s New Times
I’ve been helping the New Statesman launch a new podcast, which asks their contributors to make sense of the new times we find ourselves in – Brexit, Trump, and what on earth the left should do in response.
Audio Production Awards
Amazed to have been shortlisted for Best Newcomer and Best Podcast Producer for my work with the New Economics Foundation. Thanks to Huw, Kirsty and everyone at NEF!
Podcast production showreel, 2016
I’ve produced a lot of podcasts in the past year - here are a few highlights.
Cameron’s Lament
What did David Cameron sing on the way back into Number 10, shortly after his resignation speech to the press?
It’s been the source of much speculation, and the best attempt comes from Classic FM’s blog. The answer seems to be: no one quite knows.
Composer Thomas Hewitt Jones went one step better. His new composition, Cameron’s Lament, takes Cameron’s motif and casts it as a tragic reverie through a failed political career.
Producing that week’s Weekly Economics Podcast, I just had to use Cameron’s Lament to open the episode - harkening back to voices now lost in the mists of time (goodbye to Osborne, for now, and his oft-repeated ‘long-term economic plan’), and looking ahead to May’s Britain.
Complacency
On this, the day of Farage’s third resignation from the UKIP leadership, having achieved nearly all of what he wanted, I’m reminded of seeing him speak in St Andrews in 2009. One of the smaller lecture theatres, fair few empty seats. The audience mostly just laughed at him.
I remember someone challenging him on racist grounds then – cross-referencing leaked BNP and UKIP membership lists had revealed they shared more than a few members.
He was regarded as a fringe eccentric. Pretty sure he smoked a pipe afterwards. I imagine Brown and Cameron viewed him in much the same light.
What does the junior doctors’ strike have to do with economics?
This piece appeared on openDemocracy and the New Economics Foundation blog
Why cover the junior doctors’ strike on an economics podcast?
After all, we’ve managed to run for a year, 44 episodes, and a six-part miniseries tracing the history of neoliberalism without more than an occasional mention of healthcare. Each week we cover a big economic story and try to give a balanced but alternative take on the issue. The NHS just hasn’t come up all that much.
But as Dr Ben Bouquet, public health registrar and junior doctor, explains this week, few areas of public policy are as intertwined with economic ideology as health.
Despite Treasury and DH announcements, reannouncements and re-reannouncements of billions more in funding (all of which invariably turn out to be different ways of counting the same money), the NHS is mid-way through a decade of relative austerity. At the same time, it has been a playground for successive governments to try out the marketisation of public services under the guise of increasing efficiency.
The result: high transaction costs, costly private debts, and diktats from central NHS bodies urging commissioners to financially penalise struggling trusts lest the Treasury’s £10bn surplus target for 2020 fall by the wayside. As for the strike, the dispute over junior doctors’ contracts can be tricky to follow, not least because what’s on offer keeps changing, but at the heart of doctors’ concerns about safety is the fear that the NHS is becoming increasingly thinly spread. Is all of this a false economy?
There are two big points to challenge that we often cover on the podcast in the abstract, but which manifest themselves in healthcare particularly clearly. And if we can win them anywhere, we should be winning them in the NHS.
First, that the ‘rules of the game’ that have formed the mainstream of economic thinking since the 1980s can be applied to anything. Collected together, these are often labelled as ‘neoliberalism’. (If capitalism is the game, neoliberalism is one of several sets of rules you could choose to play by.) As economist James Meadway told us back in June, the core tenets are broadly that individual choice is king, free enterprise knows best, and governments should play a limited role in the economy except in creating and promoting markets. But when choice is limited by urgency or complexity, free enterprise can’t offer more caring or efficient services than the public sector, and marketisation leads to high transaction costs and perverse incentives, we’re left with plenty of evidence to the contrary.
Second, and perhaps more difficult, is the assumption that healthcare is a burden rather than an investment.
On an episode about feminist economics with Polly Trenow from the Women’s Budget Group, we talked about the idea of social infrastructure. The economics of physical infrastructure is easy to understand – build a bridge, and the people from the other side of the river can come and buy things in your shops and work in your offices. If you’re a politician, you also get to wear hi-viz and a hardhat. But social infrastructure is just as vital to our economy. Just one example: grandparents who now live healthily into old age, thanks in no small part to the NHS, provide childcare worth around £4bn a year, though you won’t see that care reflected in GDP figures.
George Osborne likes to say that you can’t have a strong NHS without a strong economy. But I’d argue it works the other way round: you can’t have a strong economy without strong social infrastructure, and that includes having an effective health service.
In developing countries, investing in reducing infant mortality means families typically have fewer children. Having fewer children means they can spend more per child. Spending more per child means each child gets more food, more education and more opportunity, meaning that child can be more productive and help pull the country out of poverty. Strong healthcare is a catalyst for growth, not an afterthought once your country is already rich.
These assumptions – that social infrastructure is a burden on public finances, not an investment in creating a productive society, and that neoliberalism should be applied everywhere – are at the root of current problems in the NHS. And we can only unpick them if we understand them. Hopefully the Weekly Economics Podcast is doing its bit, 15 minutes at a time.
Podcast production is the reason I can't go all-in on iPad just yet
My day job is as a healthcare policy analyst for a big charity. This post is about my other work, as a podcast producer – and is a response to educational tech writer Fraser Speirs’ recent post All-in on iPad Pro.
This year I produced 42 podcast episodes for a think tank here in London called the New Economics Foundation. Since February we’ve launched the Weekly Economics Podcast, which peaked at #3 on the UK iTunes chart and has been featured in the Observer, the Independent and the Guardian; the spin-off miniseries A Beginner’s Guide to Neoliberalism; and a new project with a pilot coming out in the New Year.
At the heart of the production is an 11-inch MacBook Air and Logic Pro X. Each week I show up at NEF’s makeshift studio, plug in the audio interface hooked up to a couple of AT2020s and occasionally the best pro-am podcasting mic of all time, and we’re ready for another interview with an economist.
Once recording is done, I often heavily edit the interview and voiceovers, add compression and EQ, edit the music, create a montage of news clips gathered using Audio Hijack, sometimes add effects, use loudness metering to mix the show, then export to MP3 and add metadata. After a few hours, an episode ends up sounding a bit like this:
Volume, pan and effects automation is a big part of the way I work. Sometimes this is for simple tasks, like making loudness consistent when an interviewee isn’t always exactly on-mic. But I also build more complex montages, automating dry and wet reverb levels and building idents for new shows. Here’s how that can end up looking in Logic:
And the end product is something that sounds like this:
I don’t know how I would do something like that on an iPad, though I’m hoping someone will point out how ignorant I am and show me how. I’ve read great things about Ferrite Recording Studio from people like Jason Snell (whose Incomparable podcasts I love), but at this point I get the impression I’d be rather hamstrung in a few essential parts of my production workflow:
Multitrack recording from external interfaces: I know there are a few audio interfaces that are compatible with the iPad via the USB Camera Connection Kit, and our Alesis iO4 is one of them. What I’m less clear about is how an app like Ferrite handles three or four tracks of input, or 24-bit sources – there doesn’t seem to be a mention of this in its user guide.
Downloading music from the Free Music Archive and using it in a mix: FMA is a wonderful source of Creative Commons music, and I have a few gigs of the stuff in a library I put together especially for podcast production. Adding music looks to be easy in Ferrite, but downloading from the web first is another issue.
Audio Hijack: capturing and importing news clips and the more ridiculous things our politicians say about economics is an essential part of my workflow for the Weekly Economics Podcast, though I know most podcast producers will get by just fine without it. iOS’s restrictive audio policies mean this isn’t possible on an iPad yet.
Loudness metering: all podcast producers should know about and use loudness metering. If you don’t know your LUs from your LUFS, you’re probably spending more time than you need to trying to mix audio by ear or by using misleading VU or PPM meters, and ending up with inconsistent levels within and between episodes. On the Mac, I use the free version of Klangfreund’s brilliant loudness meter Logic plug-in, and the paid version looks even better. I’ve yet to see an iPad app include this feature – but again, I’d like to be proved wrong. My guess is that this might be possible as an AudioUnit Extension in iOS 9.
Effects and automation: I probably use 5% of what Logic is capable of when it comes to effects, but I like that if I can imagine a sound, it’s usually possible to create. Ferrite’s effects and automation features are truly impressive for an iOS app, but as a user and abuser of Logic’s Space Designer and excessive reverb, echoes, looping and speed effects, it would leave my projects without some of their more grandiose production moments.
There are so many other features Ferrite gets right that I’d love to be able to jump in feet first. The crossfading, the automation (including on effects parameters, hallelujah), strip silence and quick selection of all following clips are all things I didn’t think we’d see on iPad for a while. But it feels as though we may still be a couple of years away from covering all of my particular bases, not least because of iOS’s restrictive audio policies that make apps like Audio Hijack impossible.
Developers like Wooji Juice, who make Ferrite, are the people putting the Pro into the iPad Pro. I can’t wait to see what they do next, and feeling like I live in the future, walking into a recording studio with only an iPad in hand.
Five thoughts on what the Chancellor’s spending review means for people affected by cancer
This piece first appeared on Macmillan Cancer Support’s ‘Evidence and Influence’ blog
It was widely reported last week that George Osborne has committed billions of pounds of ‘extra’ money for the NHS over the next five years as part of his Comprehensive Spending Review. But what is the bigger picture for healthcare, social care and welfare, and what will the announcements mean for people affected by cancer?
1. Extra funding for the NHS is welcome – but it needs to be spent wisely
It is good to hear the government is investing in the NHS’s plan for the next five years, and that £3.8bn extra will go into the NHS next year; our creaking health service badly needs this money now.
But three quarters of England’s hospitals are now running a deficit, which by the end of the year is expected to hit £2bn. We have seen the impact of this pressure on frontline cancer services: cancer waiting time targets have now been missed for seven quarters in a row. In the short term, the extra money will help to plug the black hole in NHS balance sheets, which we hope will mean getting back on track with meeting existing targets.
It is now crucial that the government spends wisely and fully funds and implements the cancer strategy for England which will be transformational for cancer care. Although the cancer strategy was mentioned in the Spending Review, this was only to reiterate a commitment to implement the previously announced recommendations on a new 4-week target for diagnosis and improved diagnostic capacity through £300m in funding.
As we said in October, time is running out: by 2020, there will be half a million more people living with a cancer diagnosis in England than in 2015. The strategies and solutions to support this growing population and avoid further crises have been agreed – what we need now is action. Macmillan will continue to push for the cancer strategy to be implemented in full.
2. We often hear that to have a strong NHS we need a strong economy – but despite extra funding, the NHS is not receiving its fair share of the proceeds of growth
The Government has often said that we need a strong economy to have a strong NHS. The reverse is just as true – we need a strong NHS and a healthy population to have a strong economy. As the economy returns to growth, we should invest in the long-term health of the nation. But on the evidence we saw in the Spending Review, it looks as though health and social care funding are going in the opposite direction.
Billions of pounds of extra money is a big investment, but as the population ages, more treatments become available and more people survive diseases such as cancer, the demand for healthcare could still outpace funding. Even with the additional money, we are now mid-way through the longest decline in NHS funding as a percentage of GDP since the war:
Source: King’s Fund
What does this mean for cancer services? The picture is unclear: we don’t yet know how the NHS will use its funding allocation, and will find out more when NHS England’s plans are published in early 2016.
What we do know is that between 2010-2013 spending per cancer patient had already fallen by between 4-10% (the latest figures available).
It can be difficult to know whether healthcare funding necessarily leads to a healthier society, and not all high-spend health services get value for money, but there comes a point where it is clear that more could be done with additional funding, and this is true of cancer.
In comparison with the rest of the world, both our level of healthcare spending and our cancer survival rates fall short. Last week’s announcement means that over the next five years, the share of GDP the UK spends on the NHS will fall even further below European and OECD averages:
Source: Nuffield Trust
3. Cuts to public health and bursaries for nurses are counterproductive
We understand much of the extra £3.8bn for the NHS next year is in fact sourced from a 25% cut to the Department of Health’s non-NHS budget.
It is counterproductive that ‘extra’ NHS money is being sourced from cuts to public health (which includes cancer screening and smoking cessation clinics) and bursaries for student nurses. This precious investment should be used to drive genuine progress – instead, it is being used to paper over the existing cracks.
Local authorities’ public health budgets will also fall by an average of 3.8% in real terms each year. The public health ring-fence will be ‘maintained until 2017/18’, which implies it might not continue afterwards.
This means the Spending Review has failed to meet one of the ‘five tests’ set by the head of the NHS, Simon Stevens, for the Spending Review – to “make good on the public health opportunity”.
4. We’re still concerned about social care funding
Funding the health service is just one side of the coin. The needs of people living with cancer are often life-long, and many require non-medical support to get by.
We are concerned that continuing pressure on social care budgets means that extra funding given to the NHS could end up being spent propping up a cash strapped social care system.
George Osborne announced a new optional levy on council tax of up to 2% per year, which is to be ring-fenced to fund adult social care. But commentators are suggesting that even if this is implemented by every council each year there will still be a substantial funding gap.
Perhaps even more problematic is the risk that access to social care could become more of a postcode lottery and exacerbates health inequalities by disadvantaging councils with weaker tax bases. According to the Institute for Fiscal Studies, councils such as Manchester, Hackney, Liverpool, Newcastle and Birmingham could only raise an extra 4%, while Richmond and Windsor could raise 17-18%. Meanwhile the King’s Fund warned the measures “are not a substitute for sustainable funding”.
No other advanced economy is reducing the share of national income spent on social care, as the UK is doing. We know that during the first few years of the last parliament’s social care cuts, over 360,000 fewer older people received social care than before. It is difficult to be optimistic about the future of social care against this background.
5. The welfare situation has changed less than the headlines suggest – and we will do all we can to be there for people affected by cancer
One of the big headlines after the Spending Review was the government’s supposed u-turn on its controversial proposals to cut Tax Credits. While we welcome this change because we know many people with cancer use this financial support, this is only a short-term gain, as the same cuts will continue to apply to Universal Credit, which is already being phased in.
Despite talk of u-turns, the impact of tax and social security changes over the next four financial years will be the same as first estimated after the July Budget statement (the poorest 20% will still be around 7% worse off). The Chancellor also reiterated his commitment to implement £12bn of savings, part of which is the already announced cut to ESA WRAG, which we are campaigning to stop.
Macmillan believes it is vital people affected by cancer get the support they need through the social security system, so monitoring and responding to the introduction of Universal Credit will continue to be an important part of our work.