Three myths about Johnson’s Social Care package

Most of the controversy around the extra spending for the NHS and social care announced last week focused on the higher rates for national insurance. As Rachel Cunliffe explained here, national insurance contributions are a tax just like income tax or VAT. The misconception that they are payments into some pot of money that you get back later helps explain why this was the tax of choice for Johnson, although the fact that it is not as progressive as income tax (excluding, in particular, rent or interest income) probably helped too.

I'm not going to talk about why national insurance is a very bad way to fund this additional spending because that has been covered elsewhere. However my first myth is that this unfairness has something about ‘generation wars’. When the post war Labour government introduced the state pension in 1946 I don’t know whether anyone said that because money was being taken from the young to give to the old (true) it was unfair on the younger generation, but if they had it would have been nonsense. It is difficult to get your head around, but with that kind of scheme, the old at the time it starts gain a huge amount, but there is no corresponding loser if the scheme continues forever. Some things are about generational transfer (like higher house prices), but schemes where the young will benefit when they are old are not. [1] The reason to oppose the use of national insurance is on normal equity grounds considering who benefits, rather than anything intergenerational.

The second myth I want to talk about is that this package shows that this government is not Thatcherite, or Osbornite, but instead favours a bigger state (and therefore it is more left wing). This myth is believed by a number of Tory MPs, some journalists (the Telegraph’s editor even called it the triumph of socialism) and some on the left. The reality is that it shows no such thing. Instead it is just bowing to the inevitable consequence of having a state funded health service.

The fact of life that few journalists are prepared to admit, and many Tory MPs pretend not to understand, is that in economies such as ours the share of health spending in GDP rises over time. This is something I have talked about for some time, ever since Osborne pretended that he was ‘protecting the NHS’ which journalists parroted. Here, for example, is a post from 2015 that shows a graph of the share of NHS spending in GDP rising from 3% of GDP in the 1950s to over 7% in the 2010s.

There are a number of reasons for this. As our incomes rise our wish to spend money on our health rises faster than our income, while our spending on food (for example) rises less. Doctors are finding better ways (or sometimes ways that didn’t exist previously) of treating us, which often seems to involve expensive drugs or capital equipment. But perhaps most important of all, we are on average living longer but the age our bodies start needing attention has not been rising so rapidly. This point applies to social care as well as the NHS. 

The inevitable consequence is that taxes need to rise to match this rising spending. [2] This was masked for a long time by an opposing trend: falling defence spending as a share of GDP. That however came to an end certainly by the turn of the century, which is why the Blair/Brown government increased national insurance to get the NHS to a reasonable level of operation. In contrast Cameron/Osborne were able to run the NHS into the ground again not just because they ran a right wing, small state government, but because they used the false excuse of a runaway government deficit which most of the media and the public believed and because their squeeze began from a fairly good position.

This chart, of how many cancer cases were treated within the target number of days, shows what happened clearly.

This chart is one of many that show a gradually deteriorating health service since 2010: see here for more information.

This deterioration has stepped up substantially in 2020 because of the COVID pandemic. No government, whether left or right, could have failed to react to this, if it wants to survive in office. So Johnson had to put additional resources into the NHS to clear the backlog created by COVID, and that is what the higher national insurance increase is initially about. It does not make him left wing, it does not raise the scope of the state (which is what really matters politically), and it certainly doesn’t herald a victory for socialism.

At this point we do need to ask whether permanently higher taxes make sense for what is a temporary problem - clearing the COVID backlog of cases. Just as most of the costs of COVID have been paid for with borrowing, why not this? It makes no macroeconomic sense to raise taxes now to cover transitional spending. The obvious answer to this puzzle is that nothing has changed since Osborne, in that we still have a Chancellor who is distorting economic policy just so he will meet some arbitrary deficit targets. This, in turn, is why it is so inaccurate to describe this as a left wing, big state government. Talk to those in local authorities, or in criminal justice, to see that Sunak (whatever Johnson’s wishes) continues to be a small state Chancellor.

But there might be another reason why the government chose to permanently raise taxes? This brings us to myth number three, which is that this package is about improving the quality of social care, even in the longer run. In the short term most of the money raised by the new tax will go to the NHS. What is left for social care will have to cover the cost of reducing the amount the elderly need to pay for their care (but not their living costs). As the IFS says, this aspect has not been costed by the government, but “can be expected to be several billion pounds a year.” Not much if any will be left over to improve the quality of care for the next three years.

Thus the IFS writes

“While the precise path for spending – and hence for the availability and quality of care – is unclear, it is clear that the extra funding will not be sufficient to reverse the cuts in the numbers receiving care seen during the 2010s. Thus, while more people will become entitled to financial support as a result of the reforms planned, many people with care needs not considered severe enough will continue to miss out.”

Even the cap on personal social care costs will not necessarily prevent some people having to sell their homes. If your only asset is a £200,000 flat or house you still have to find the 86,000 that is the cap on payments. The government responds by talking about a growing insurance market, but that market is small at present for obvious reasons (adverse selection) and that will not change much with these plans.

What will happen in the longer term, once the pandemic backlog has been dealt with? Here we have to come back to the state of waiting lists before COVID. The NHS does not just need money to catch up with the backlog caused by COVID, it needs money to stop (and even reverse) the deterioration in waiting times that began under austerity.

There are other pressures on NHS budgets too. One is pay. It is not sustainable to keep funding the NHS by decreasing the real value of nurses’ pay. Another is privatisation. The bill currently going through parliament gives ministers the power to circumvent normal procurement rules (competitive tendering), and their past actions suggest they favour giving contracts to private sector friends rather than allowing the NHS to do work in-house. Whatever these private sector companies may claim, that means higher cost to the public sector to fund the profits these companies need to make. [3]

The risk therefore is that after three years not much, if any, of the money created by the national insurance tax increase will end up in social care. As Graham Atkins of the Institute for Government says, “There is a risk that the funding for the NHS to tackle backlogs goes into the baseline NHS budget and the funding never ends up going to local authorities to reform social care.” This risk will be intensified if the government continues to squeeze local authority budgets, which in the short term at least seems likely to happen as Sunak tries to meet his deficit targets.

If higher taxes were really for social care, then it would have made sense to give the NHS temporary money to cover costs arising from the pandemic by borrowing, and direct the funds from higher taxes to social care immediately. Better still delay the tax rise but increase funding straight away to give the economy the boost it clearly needs. One of the reasons this didn't happen is that the NHS needs more money on a permanent basis, and Johnson is a Prime Minister who knows further deterioration in NHS waiting times beyond 2019 levels will risk losing power. Thus the tax increase says very little about the ideology of this government, and instead reflects the continuing desire of Conservative Prime Ministers to retain power. .

[1] The young could lose a bit if they could do better saving themselves and then investing in social care insurance, but when that insurance is scarce and expensive because of adverse selection it seems unlikely.

[2] This is a red flag to twitter MMT, who will say you could borrow or create money instead. But doing so year after year will overheat the economy, so if we are talking about several decades it’s not a very helpful remark. I talk about the immediate short run below.

[3] The usual counterpoint to this is that the private sector have more of an interest in improving efficiency. While that may be true in some areas, it seems highly unlikely for the NHS. The inefficiencies in the current NHS largely stem from a lack of public sector investment.

Coronavirus and the consequences of a compliant media

This hasn’t been the new government’s first nationwide crisis. That was widespread flooding hitting many regions of the UK. As I explained here, that was partly a disaster created by the Conservative party (with a little help from their coalition partners). Journalists had their chance to make a story out of this by using the hook of Johnson’s non-appearance at any of the flooded towns, but it didn’t happen, just it didn’t happen on all the previous occasions we have had widespread flooding. Which is why spending on flood defences continues to be inadequate.

Lack of criticism encourages a certain laziness, but also gives politicians the courage to do things that those in democracies with more accountability would not do. I think we can see both in the coronavirus crisis.

In the initial phase of the UK pandemic, where cases were mainly coming via contact from abroad, the NHS were trying to prevent infections by tracing and getting those who had contact with the virus to isolate themselves. For that phase to have any chance of working, the Prime Minister needed to impress upon the country the importance of voluntary social distancing, so that cases the health service missed did not pass the virus on. Instead the Prime Minister continued to shake hands as if nothing had happened. He even suggested the media was overreacting to the virus.

That was a very personal example of laziness. But more generally the government needed to get across the seriousness of the situation without creating widespread panic. The best way to do that is to create social solidarity and trust in government. You create trust in government by openness. It is not good enough to say you are following the science and not be honest about the science and the alternatives available, so everyone can understand why you are taking a particular course. .

The government started from a difficult position because its actions elsewhere had created a very divided society. There would always be those that questioned what they were doing. But if the government really was following the science, and it was obvious to anyone who investigated the literature the government released that it was following the science, then that politicising of the government’s approach would have been limited.

You can see this in the behaviour of the opposition. They initially did not question or criticise what the government was doing. In a crisis they were prepared to give the government the benefit of doubt. But if that was to last it required bringing the opposition alongside as part of a national effort, by for example including an opposition minister or the mayor of London in COBRA meetings.

None of this happened. One of the reasons it didn’t happen is that the government knew it faced a largely compliant media. On social media there were enough friendly voices to try and shut down those who “questioned the science”. Blunders came and went with no consequences, such as Hancock’s premature claim that he was working with retailers, the 111 service giving the wrong advice and with too few staff to take calls, and delay in checking at airports and getting people to quarantine themselves.

The government’s strategy, of keeping information tight and endlessly repeating that they were following the science, might have been enough if it hadn’t been for many other countries following a different path to the government once it was clear that the containment phase was not working Other countries seemed to be introducing more stringent measures to ensure social distancing than our government. A few, like Italy, were doing so because the pandemic was uncontrolled and they had no choice. But other countries, like Ireland on our doorstep, did it from choice. It seemed clear that the UK was following a different path and it wasn’t clear why. When people like the editor of the Lancet started questioning the strategy, news programmes like Channel 4 News and Newsnight began to ask questions. And those questions were not answered.

People started taking their own actions to ensure social distancing. Universities started teaching online and large events were cancelled. Then Scotland jumped ship and suspended large gatherings, and later the football league suspended matches. At that point the government, which was supposedly following the science, seemed to panic and follow Scotland’s lead. Rather than the government leading a national effort, it appeared to be playing catch up.

I think it is fair to say that the government’s communications strategy has been chaotic. You cannot communicate to people in a crisis like this with occasional press conferences and off the record briefing to the odd journalist, or with your health minister writing behind paywalls in the house newspaper. You cannot pretend that you are aiming to protect the vulnerable and elderly when you offer no guidance to those groups to limit social contacts. You cannot keep saying you are following ‘the science’ when most other countries are doing something very different, because science is international. And you cannot tell people questioning your approach to be quiet to stop panic when you brief a journalist to say

“What keeps ministers and officials awake at night is the fear that if the epidemic becomes too great they would have to make appalling decisions, such as that the NHS would stop treating people over a certain age, such as 65.”

Alot of this is laziness encouraged by the belief that most of the media will back you come what may. But I also want to talk about risk taking, and a good way of introducing this is to look at this clip from the Irish media talking about how they see the UK strategy. Please also read James Meadway’s comment, which is very pertinent to the subject of this blog. Please view and read it before continuing.

In this Irish view, and many who have tried to work out why the UK strategy seems more laid back than elsewhere, the UK idea is to generate widespread immunity before winter hits the NHS and social distancing no longer works. The idea is to flatten the curve, but not too much. It is the only explanation I can come up with for the comparative lack of action in the UK compared to elsewhere, including Ireland. So let us suppose that is the strategy.

Other countries are trying to flatten the curve by much more, and perhaps even with the aim of eventually being to make the ‘contain phase’ work. That seems to be the idea in China. I don’t want to speculate on which strategy is right or wrong, because I don’t have the skills to do so (although this is a strong critique of the UK approach). What I think is worth noting is that the UK strategy is very brave from a political point of view. In the short term it is quite likely that a lot more people will die in the UK than in other countries. And while the UK strategy may be proved right in the longer term, there will always be a risk that this will not happen.

Many politicians, subject to a reasonable and fearless degree of internal scrutiny, would reject the UK strategy as just too risky - for them. However if a politician is not subject to strong internal scrutiny, they might be tempted to take a greater risk. That may be what is happening in the UK, as it is happening with Brexit. With Brexit it is people getting poorer, but with this crisis it is people dying.

This is particularly the case when the UK more than other countries has a health service that has been stripped to the bone, working at more than full capacity at normal times. This may be the reason that the government has adopted this strategy - it is trying to avoid a larger crisis developing at the worst time for the NHS at the beginning of next year. Capacity constraints in the amount of testing it can do may have caused the government to abandon widespread testing so soon, including testing NHS staff. The government doesn’t believe it can keep enough social distancing going until this time next year, even though it would have six more months to prepare.

Here we come to the major reason why weak media scrutiny puts this country at far greater risk than elsewhere. We have had 10 years where the NHS has been starved of resources, and the media has been shamelessly repeating the government line that the NHS has been protected. Every medic knows that you cannot keep spending on the NHS constant (even in real terms) and not end up with an NHS crisis. Yet this government spin has been repeated ad nauseam. And then of course we have had Brexit which has robbed the NHS of invaluable doctors and nurses. The government took a huge risk with the NHS by implementing austerity and Brexit, and they could do so because of a largely compliant media. Now many people my age and older could end up paying the ultimate price.

Update 17/03

So yesterday, if you listen to the BBC, “the science changed”. Yet in reality a good bit of why the advice changed was obvious to many before it changed: just look at this clip from Irish TV. More detail here and here. That it took those advising the government longer than many outsiders to see what was wrong should be the subject of an inquiry once this is all over. We can only guess what happened. Plans drawn up for a more serious than normal flu pandemic became part of internal government groupthink, when in fact we should have been treating this pandemic as something we should suppress rather than control. It also seems, incredibly, that not enough time was spent telling politicians about the risks involved in following their original strategy.

Even now I worry that the government is being too 'British' about this, with lots of advice and recommendations. When is travel essential? Here and here are examples of what happens when that advice is not followed, because no sanction is attached to not following it. Three other points that are now clear. First, the government did not prepare for all this early enough, and the media should be giving them hell for this failure. (Most of the media won't, for reasons described in the post.) Second all those who said people had no right to criticise because the government was following the science now look extremely foolish, and they need to admit their mistake.

But third and most importantly, the majority of the media that gave very little time to the concerns of others need to reflect on how many lives their inaction may have cost. As James Meadway reminds us, it was Amartya Sen who suggested that a free press meant less deaths in famines, and now we can see why.    

Some thoughts on Labour's campaign

The importance of this election cannot be overstated. Voters have a choice between re-electing a government that since 2010 has done untold damage to this country and which will be led by someone totally unsuited to be Prime Minister, or giving a minority Labour government a chance to do better for a few years. The fact that the polls suggest the public want more of the same illustrates how close we are to becoming an authoritarian, populist (in the Jan-Werner Müller sense) right wing state where it becomes very difficult for any opposition to break through.

This post looks at some key aspects of Labour's campaign so far, in I hope a helpful fashion.

Tax and spend

One of the dangers Labour faces is that they appear to be promising too much. Voters are skeptical of manifesto promises at the best of times, even though evidence suggests that in the past most manifesto pledges are fulfilled. If you promise so much it is possible voters will just not believe you can do all this.

In contrast the Tory manifesto is positively frugal. But there is a reason for this, and neither Labour nor the Liberal Democrats have emphasized enough why that is. Labour are not used to trumpeting the results of IFS election analysis, but on this occasion they really should. That analysis shows that one economic issue alone dominates the future of the public finances: Brexit. Here is the key chart

What this chart shows is that all these give-aways do not come close to matching the amount of tax we will lose if Johnson keeps his pledge not to extend the transition period. The reason the Tory manifesto is frugal is they cannot afford to do anything with any fiscal cost and implement a hard or no deal Brexit. Both Labour and the Liberal Democrats can afford much more, because they are not planning a hard Brexit. 

Perhaps Labour and the Liberal Democrats are reluctant to talk about this because it is going over ground covered in the referendum, and most Leavers just do not believe the economic consequences of Brexit will be negative. Yet the IFS has considerable credibility, particularly in the media. Furthermore the sparse Tory manifesto is a tactic admission that, whatever they say, the Tories believe the economy will take a hit from Brexit. Labour and the Liberal Democrats should make more of this. 

Protecting minorities

Labour should not just be defensive on charges of antisemitism. These attacks on Labour over the small amount of antisemitism among members distract not only from the more extensive racism in the Tory party and its actions, as Jonathan Lis describes so clearly here. It also distracts from the rise of right wing hate-crime. That the problem is growing is pretty clear. Attacks mostly involve race and sexual orientation, but it includes attacks based on religion: mainly Muslims but also Jews. Commenting on the steady rise in ethnic or religious hate crimes Dr Chris Allen said:

“The statistics show that for the third year in succession, religiously motivated hate crimes have not only increased in number but have again reached record levels. While some try to explain this as a result of better reporting procedures, doing so is over simplistic. From our research at the Centre for Hate Studies, one cannot underestimate the impact of Brexit and the divisive rhetoric employed by politicians and others in the public spaces. Affording permission to hate a whole range of ‘Others’ – especially Muslims and immigrants – it is likely that the upward trajectory of hate crimes numbers will continue for the foreseeable future.”

The police say that the alt-right is the fastest growing terrorist threat in the UK. A third of all terror plots to kill in Britain since 2017 – seven out of 22 – were by those driven by extreme-right causes.There is nothing comparable on the left. One Labour MP was tragically killed by a far-right terrorist during the Brexit campaign, and at least one serious plot against another has subsequently been foiled. The alt-right is well organised at an international level

What has that got to do with this election? The rise of the far right did not come from out of the blue. Campaigns against immigration, and particularly for Brexit, have encouraged racists into the open. So has over the top language used by Brexiters. It has mainstreamed xenophobia, and maxed out on crude nationalism. The media, particularly the right wing media, are happy to give a voice to anti-Muslim writers.

What will the current government, if it wins this election, do when Brexit does not lead to any improvement in people’s lives, and indeed makes them worse? The Tory manifesto has virtually nothing about redistributing opportunities in a more equal way across the country, and Brexit will not help. If the recent past is anything to go by, they will blame immigrants even more than they do now, which will only increase the threat from the far right.

Scotland

Do you remember pictures of Ed Miliband in Alex Salmond’s pocket? These came from the Tories towards the end of the 2015 election, when it became clear that Labour could only win with the SNP’s help. It wasn’t repeated in 2017, in part I suspect because no one on the Tory side believed Labour would do anywhere near well enough to make that attack line effective. I suspect they will not make the same mistake this time around.

The Tory attack was credited by some as helping Cameron get his majority, although I have no idea how true that is. But if Labour is attacked along these lines in a serious way in the final days of the campaign, what should they do? They shouldn’t do what they have done so far, and just say they will not do any deals. This doesn’t work because voters believe maths more than they believe politicians, and they remember the 2010 Coalition talks and the Tory give-away to the DUP.

What Labour should do instead is dig out one of the quotes where Sturgeon has ruled out allowing the Tories back into government and repeat it endlessly. If any interviewer asks why that is relevant simply point out in the most tactful way that the SNP only has bargaining power over Labour if they are prepared to put the Tories in power instead, and they have ruled that out because it would be political suicide for them. Not putting the Tories in power means they have no leverage over Labour.

The last week

The SNP (and of course antisemitism and law & order) are going to be part of the Tory’s lines to take in the final week, and they are likely to throw in a letter from business leaders if they can find enough willing to sign it despite Brexit. What should Labour emphasise? There is an embarrassment of riches to choose from. They could talk about

Revitalising the economy with public investment directed at the regions

Building more social housing

A Final Say on Brexit

Nationalisation and Free Broadband

Education

Revitalising bus services

A Green New Deal

Saving the NHS

And probably much more that I have forgotten about. Talk about them all and there is a danger nothing really hits home. More than ever before there will be an intense battle between the two major parties to get the media to talk about the topic they want talked about. In 2015 the media chose the SNP rather than the NHS which Miliband wanted to be the focus. In hindsight that represented terrible judgement by the media, but importance isn’t their key consideration.

What works best in getting airtime is to present something new. It could be a letter on the Tories climate change policy like this. It could be a new statistic on poor health service performance which should not be hard to find, or some gaffe by a senior Tory (like this). They can always use this. These are also the two obvious issues to focus on in the final day or two.

On climate change you can say that we cannot waste another five years before we take serious action. This is aimed, above all, at getting out Labour’s core younger vote. The NHS will have much greater resonance with the Tory core vote, and might discourage these voters from voting at all. On the morning of the election the newspapers most elderly people read will be full of scare stories about Corbyn, so Labour needs concerns about the safety of the NHS under Johnson, Trump and Brexit to counteract that.

Health spending over time

There has been some comment on the fact that, with recent increases in spending on the NHS, the health budget is taking a growing proportion of UK state spending. I am missing Flip Chart Fairy Tales, so here is a chart heavy post to make one or two obvious points that regrettably are often missing from political reporting.

The first is that health has been taking up a growing slice of our total expenditure (i.e.GDP: expenditure on everything including investment) for a very long time. Here is a chart from a recent IFS publication which is a good source for more in depth analysis.

Note that real spending numbers can be misleading: although real spending has increased since 2010, as a share of GDP it has not, which is a reversal of previous trends. That alone does not inevitably explain recent problems in the NHS, but it certainly could do.

So why is it only recently that the growing share of public spending has been so obvious? Again the IFS have a handy chart that goes a long way to providing the answer.

In 1955/6, defence spending was over 20% of total spending, while by 2015/6 it had fallen to just 5%. This peace dividend (actually two: first a retreat from empire and then the end of the cold war) masked a steady rise in heath, which was only 7.5% of total spending in 1955/6 but was approaching 20% by 2015/6.

Many economists would simply describe this as reflecting that health was a luxury good, which means that spending as a share of income rises when income rises. Not all the evidence confirms this, e.g. the spending patterns of lottery winners. In reality I think there are various things going on. One may be that medical science has got better at prolonging life faster than it has held back the aging process. Another is that medical innovation is increasing the scope of what medicine can do. For example cancer is now increasingly survivable, but only with expensive care. While there is productivity growth in the NHS, it is below the national average and therefore fails to match increases in wages. In the document all the figures so far come from, the IFS expect these factors will require real health spending to increase by 3.3% each year over the next fifteen years.

Politicians, particularly those adverse to taxation, love to think that some kind of reorganisation will somehow change the inevitability of an increasing share of government spending and GDP. But this chart, taken from this source, suggests these trends are not some peculiarity of the way we organise things in the UK

In 1970 health spending was between 4-6% of GDP in these 5 countries, but by 2016 it was between 9-16% of GDP. (There is a definitional break in the UK series in 2013: there was no leap of spending in 2013 as earlier graphs show.) If there is any organisational lesson here, it is not to run a health service in the way they do in the US. It is indicative of the mess the world is currently in that politicians are busy trying to dismantle the positive recent reforms in the US and key politicians in the UK have once talked about making the UK health system more US like.

If the IFS is right, this inevitably means that taxes of some kind will have to rise significantly. Yet the Conservatives have repeatedly pledged not to raise any of the headline taxes, and Labour have felt compelled to match these pledges at least in part. That the budget included increases in the tax thresholds, and Labour’s internal spat over whether to vote for them, illustrates nothing has changed in this respect. This year this tax/spend dilemma was avoided by a tax windfall no one had forecast. But at some point in the near future something will have to give, and I really hope it is not once again the quality of our health services.

A comparison in accountability: Oxfam and the NHS

Although the original allegations in the Times looked weak, it turns out (from an interview with ex-employee Helen Evans by Channel4 News) that the leadership at Oxfam had not been giving the issue of exploitation by a tiny minority of its aid workers the attention it deserved. The deputy chief executive has resigned.

The original allegations concerned actions by some aid worker in Haiti some years ago. Oxfam took action at the time, and the charity has put in place various safeguards since. But nevertheless, it is important the media holds charities to account to ensure they do all they can to avoid this happening again.

But threatening to cut off all government funding is the last thing you should do. The message that sends to other charities is to hide any similar problems they come across in their own work, or worse still stop looking. Any responsible minister would have known that, but perhaps they wanted to get political points from their own side for being tough with a ‘leftie charity’. In none of the BBC coverage I saw (this story was the lead item on the BBC news I watched for four days running) were any questions raised about the government’s actions.

Contrast the behaviour of politicians and the media in relation to what is currently happening in the NHS. Quite simply people are dying because there are insufficient resources to cope with needs. Thousands have had operations postponed, leaving them in pain. Patients are lying in trolleys because there are not enough beds. Huge numbers, more than ever before, are having to wait for more than four hours in A&E.

The reason for all this is not mysterious. Health has been starved of resources by this and the previous coalition government like never before. I have shown the Kings Fund analysis in the past. Here is World Bank data up to 2014. The key point is that health spending as a share of GDP needs to rise to keep up with demand, but since 2010 the government has been shrinking the share of total output spent on health. The downward trend it shows until 2014 has continued and is projected to continue.

This shows neglect on a scale that make the leadership of Oxfam’s misdeeds look trivial. Yet where is the media scandal? The man who has been in charge of the NHS while this has happened and is happening in front of our noses is still in his job. The government continues to fail to provide the resources the NHS needs, while promising to protect the NHS, and yet it has not been held to account for killing people and leaving them in pain by the same media that has been happy to pursue the leadership of Oxfam. The Minister for International Development told the leaders of Oxfam that “an organisation’s moral leadership comes from individuals taking responsibility for their actions”. Quite.

The government are in denial about what is happening, and the media allow them to get away with it. Of course there have been countless reports about the crisis in the NHS, but we have not seen the kind of sustained and coordinated media focus on who is responsible that we saw with Oxfam. This is not about sexual exploitation in another country some years ago, but about people dying and in pain right here right now.

And incredibly, it is actually worse than this. The same politicians have attempted to use immigrants as a scapegoat for what is happening, whereas in fact immigrants provide more resources that could be used for health spending than they take out. Yet time and time again ministers can get away with this lie in the broadcast media. Worse still, one part of the government is busy preventing doctors the NHS desperately needs from coming to work here. And finally, I have never heard anyone in the broadcast media question why the government is starving the NHS of resources with such devastating effects. Its silence on the growing privatisation of NHS services is almost total, even though the vast majority of people do not want this.

This reminds me of the US election, where the media spent far too much time going on about Clinton’s emails and far too little time on Trump’s obvious unfitness to be a POTUS. But in this case there is no competing narrative, no two sides to balance. The media is simply failing to hold the government to account for allowing totally avoidable death and pain. This is what the UK has become in just seven years. A country that is happy to treat those who run charities as close to criminals, but shrugs its collective shoulders while the government destroys the NHS in front of our eyes.

The Budget and Health Care

The reasons for substantially increasing current spending on the NHS and social care are obvious. Here is some data. The first is from the OECD on UK spending on health over a long period as a share of GDP (source).

This reveals an important truth which talk of ‘protecting the NHS’ is deliberately designed to ignore: health spending increases as a share of total GDP over time. The two noticeable points beyond that are the increase in spending under Labour, and the slight decrease in spending under the Coalition government.

One area of health spending that has been particularly hit in the recent past has been spending on social care by local authorities (source).

It is in areas like this that I get so frustrated with TV journalism. I have seen countless segments or interviews on what is causing the current crisis in the NHS and health care, but I do not remember ever seeing graphs like this. Is there an unwritten understanding in the TV networks that people cannot read graphs?

The outlook for the next five years for total health spending is further falls relative to total GDP (source).

The red bars are the projected growth in GDP, and the blue bars the projected growth in health spending. Unless something is done the current crisis in social care and the NHS will get worse and worse.

This increase in spending should be permanent and financed by a permanent increase in taxes. As such a specific tax funded increase in spending would be popular, it seems sensible to do it that way. Given the current crisis in the NHS, if this is not done in the budget we either have to downgrade our assessment of the morality of our current rulers still further, or assume they really do have an ulterior motive in running the NHS into the ground.

What would be the macroeconomic effect of such a policy change? You might expect a permanent tax financed increase in spending to have no effect. Taxes would rise by an equal amount to the extra government spending, and knowing this was permanent consumers would reduce their spending by the full amount of the tax cut. So private spending falls to offset additional public spending.

There are two reasons for thinking that would not be the full story. First, consumers initially appear not to fully adjust consumption to a tax change, even when that tax change is perceived as permanent. This is quite rational if they hold precautionary savings, and wish these savings to adjust to be a constant share of post-tax income. As a result there might be a short term boost to activity from a tax financed spending increase. This could be amplified, of course, if the tax increase was delayed for a year or two. As interest rates are still at their lower bound, such a boost to activity would be welcome.

Second, spending on health care is likely to be less import intensive than the private consumption spending it replaces. This would give a permanent boost to GDP and permanently reduce the current account deficit. Now both these effects might lead to an offsetting exchange rate appreciation, but the consequent reduction in inflation and boost to real incomes that this appreciation brings would not be unwelcome given the impact of Brexit.

Three final points that I hope are obvious. First these beneficial macro effects are incidental in the sense they are not required to justify the spending increase. The case for additional spending on health care financed by higher taxes is overwhelming on its own terms. Second, this is additional to the large increase in public investment, financed by borrowing, that should be underway right now. The changes in this direction in the Autumn Statement were an order of magnitude too small. Third, the second biggest threat to the NHS right now after lack of money are staff shortages. As an important source of staff is the EU, the government seems to be doing everything it can to make things more difficult.  

Brexit is another Iraq

In March 2003, 149 MPs voted against the Iraq war. They comprised the then much bigger Liberal Democrat party, the then much smaller SNP, 84 Labour MPs, Plaid and the SDLP, and the odd Conservative. Those voting against triggering Article 50 comprised the LibDems, the SNP, 47 Labour MPs, Plaid, the SDLP, one Green and a single Conservative. Is the similarity between these votes just a coincidence? I want to suggest not.

Let us begin by making an obvious point. You may think Iraq is different because so many lives were lost in the chaos after the war. But how many lives will be brought to a premature end because Brexit means we will have to live with an NHS in permanent crisis? Many people have not realised what a disaster Brexit could turn out to be. With a hard Brexit the CEP estimates an eventual cost of almost 10% of GDP each year. [1] That is huge: much bigger than the loss in real incomes already experienced as a result of the Brexit induced sterling depreciation. That alone could mean a 10% cut in money available for the NHS, if the share of NHS spending in GDP remained constant. But it is worse than that. If immigration falls, as the OBR expects it to, and because immigration improves the public finances, the cut in NHS spending could be a lot greater than 10%. Of course it may turn out to be not quite as bad as that, but we need to ask what exactly is the point of taking such a huge risk, just as people now ask what was the point of the Iraq war?

Iraq involved the US and the UK, whereas Brexit is just a UK affair. But think of the following mapping. The Neocons who pushed for the war are like the Brexiteers. May is George Bush, and Corbyn is Blair. Whereas Blair felt he had to go along with Bush, he also must have felt that getting rid of Saddam would be no bad thing. Whereas Corbyn and many MPs feel they have to follow the referendum result, Corbyn may also think that leaving the EU is no bad thing.

Does the referendum not make the two events distinct? The first point to make is that a clear majority of UK popular opinion (and US opinion) supported the war. Everyone of Murdoch’s papers around the world strongly supported it. However a minority of people were passionate in their desire for the war not to happen, with many taking part in the largest demonstration the UK had ever seen.

More importantly, the referendum was advisory, whatever politicians may have said. After an election the opposition does not feel obliged to start voting for all the government’s policies that they used to oppose? The idea that the Brexiteers, if they had narrowly lost, would have said ‘fair enough, we will keep quiet for 30 years’ is laughable. Most people voting Leave expect to be no worse off as a result, and would not have voted Leave if they thought otherwise. In these circumstances, the idea that the 52% majority will remain the ‘will of the people’ for very long is ridiculous.

The most important similarity between Iraq and Brexit is that both were huge decisions that were politically driven and which went against the available evidence. Hans Blix, who had been in Iraq looking for chemical weapons, thought it was a huge mistake. Chicot confirmed that the UK chose to invade Iraq “before peaceful options for disarmament” had been exhausted. Military action was “not a last resort”. The British knew that there were no serious plans for post-war reconstruction and reconciliation, but we joined Bush’s war nevertheless. It was not just a disaster, it was also a widely predicted disaster. Brexit is an almost universally predicted disaster among experts. For both Blair and Corbyn, their own misguided political views overrode expert opinion.

Just as Iraq destroyed Blair’s support among Labour party members, Brexit is likely to do the same to Corbyn. I expect the process will continue steadily over time, as bad Brexit news is greeted by Labour ministers not with a confident and resounding I told you so, but rather with feeble claims that May is enacting the wrong kind of Brexit. As the popular tide turns on Brexit, just as it did on Iraq (a majority of people now think they were always against the war), the opportunity Labour has missed by supporting Brexit will become clear. One difference is that Blair had enough popularity in the country to win a general election after Iraq, but the support of Labour Party members is pretty well all the political capital Corbyn has.

Thus the only interesting question is when Corbyn will go, and what the manner of his departure will be. I surprised a few people by saying in an earlier post that he needed to stay on for a while if we were to have any chance of stopping Brexit. My reasoning is as follows. The longer he stays, the greater will be the opportunity for the LibDems to achieve some eye catching victories like Richmond. (In the May council elections, for example.) Only then will it become clear to MPs from all parties that a Brexit backlash is the real threat, not UKIP winning in Labour heartlands. At present they and political commentators are in a Westminster bubble which is strongly influenced by the pro-Brexit press. That bubble needs to be pricked by events. If Labour switch leader and start opposing Brexit too soon, any Conservative losses could be put down to countless factors. It is vital that that a significant number of MPs begin to fear that a Brexit backlash will lose them their seat. Once (and if) that change in perception comes about, what happens next is anyone’s guess.

[1] This estimate is produced by a team led by one of our top applied economists, John Van Reenen, who has just moved to MIT.