Labour’s 2017 general election manifesto is a big break with the recent past. Whether the manifesto allows the party to make a fresh connection with the British electorate won’t be clear until 9 June. What is beyond doubt is that this manifesto proclaims that politics and government in Britain do not have to be done in the way the country has long been accustomed to. That is true, and Labour is offering the country a real choice. So far, so very good, on both counts.
Jeremy Corbyn’s biggest achievement is to put several propositions back into the arena that had been thought extinct. That does not mean all of them deserve a new lease of life equally. Nationalisation in the shape of expensive, centralised public ownership is one to treat with caution, not least because of the power it gives to trade union leaders to drive up costs. There are signs that Labour’s economic team recognises that, but not enough detail about how it can be done. Other changes, though, are more straightforwardly welcome. The most important of these concerns taxation.
For 30 years or more, taking its cue from America, British politics took it as axiomatic that all voters will always recoil from increased taxes. Understandable though this was in some ways, it was a denial of the principle of social responsibility. As a result, throughout this era, parties have had to contrive ways of providing good levels of public provision without overt tax increases. Not surprisingly, this has become increasingly hard to maintain, and the effect on public goods has often been brutal. The no-tax assumption reached its nadir in 2015 when David Cameron and George Osborne promised no rises in income tax, VAT or national insurance for all. But it was an unachievable fantasy, as Philip Hammond found in the recent budget.
Labour is right to level with voters that tax rates cannot be set in stone for ever. Governments must be able to respond to economic changes, and those that want to invest in new programmes or projects must either borrow or tax to do so. Labour proposes to do both, which may alarm some voters. But the principle that fair and necessary taxes are a mark of a civilised society is the right one, and voters understand that they must rise as well as fall. Too few parties have been honest about this in recent times – the Liberal Democrats are an exception. Today it is not just Labour that is striding boldly into this territory. Even the Conservatives see the point of keeping options open. But it is Labour that confronts the issues with welcome audacity.
The real question is whether Labour is proposing the right level of tax take and the right mix of taxes and spending. There is a discussion to be had here. Taxes on income are very important, but taxes on wealth, including houses and land, which are less easy for the asset-rich to avoid, do not get as much focus as they should. Labour’s boldness does not extend to uprating and reforming council tax bands, for instance; instead only a review into reform is promised. There is nothing in the manifesto about fuel or alcohol taxes, both of which raise money and have social dimensions too. Abolishing tuition fees is an expensive subsidy to the better-off.
It is possible that the election has simply come too quickly for Labour to work everything out properly here. Some of the changes that have been made to the leaked draft last week add to that impression, though politics is involved too. The section on Trident and Nato has been sharpened at Mr Corbyn’s expense. The earlier plan to halt NHS reforms has wisely been replaced by a review. Looked at overall, Labour’s manifesto is a mixed bag of pledges, with some strange inclusions and other surprising omissions. Though radical in some ways it is conservative in others. The section on union rights is detailed and extensive, but that on the future of the United Kingdom is perfunctory. There is not as much sense of the future as there should be.
At 124 pages, this is a long manifesto. But it is not a suicide note. In terms of its social democratic credentials, the 1983 manifesto it most resembles is that of the Liberal/SDP Alliance rather than Labour’s. Its achievement is to expand the limits of the thinkable in British politics. Its weakness is that it does too little to make the thinkable seem realistic and practical. That reflects Mr Corbyn’s preference for energising his own support rather than persuading those outside it. This manifesto may not win Mr Corbyn the general election, but it could cement his support within his party.
Thanks to this government’s intransigence about tackling air pollution, the battle to improve the quality of the air we breathe has played out not in the political arena, but in the courts. Time after time, the government has found itself on the wrong side of the law: first for its failure to meet legally binding European targets on harmful nitrogen dioxide emissions; then, for failing to produce an adequate plan to address these. Its latest delaying tactic has been to claim it could not meet this week’s court-imposed deadline for publishing a new draft plan, because of the “purdah” convention ruling out new government announcements in the run-up to an election.
And so it has fallen to judges yet again to take the government to task over its failure to act. Today’s ruling took apart the government’s case: its own purdah guidance sets out exemptions where public health is at risk. As the judge pointed out, why would it be better to have parties debating what ought to be in a draft air pollution plan, when it could be debating what is actually in it?
The government’s real motivations are political, not procedural. Having delayed taking meaningful action for seven years, it is clearly nervous about proposing any measures that hit drivers of diesel cars during an election campaign. Its political cowardice is astounding – and pointless. Public attitudes have shifted in recent years, and London’s Labour mayor, Sadiq Khan, has made tackling air pollution one of his top priorities. The government is unlikely to face opposition to tougher action from any of its mainstream political opponents, and is enjoying double-digit poll leads.
Yet it continues to shirk its responsibilities to the nation’s public health. Today’s air pollution may be less visible than the smogs that settled over our cities in the 1950s, but it is a deadly killer, responsible for upwards of 40,000 premature deaths per year. London breached its annual air pollution limit just five days into 2017, and legal limits were easily surpassed in the vast majority of local authorities. The effects are particularly pernicious for children whose lungs are still developing.
The human cost makes the government’s latest attempts to delay a disgrace. The two-month extension it was seeking for its final plan could have meant thousands of avoidable premature deaths, all in service of not wanting to jeopardise a marginal number of votes in an election that it is on course to win handsomely. It’s a sick calculus.
The good news is that air pollution is easier to tackle than other environmental and public health challenges. Unlike climate change, it is relatively localised: city-scale actions to address pollution levels can have a marked effect on their air quality. Much (though by no means all) of the problem comes down to emissions from diesel vehicles and, to a greater extent than in other areas of public health, consumers are highly responsive to financial incentives. The irony is that we know this because many have switched from petrol to diesel as a result of sweeteners introduced back when diesel was thought to be more environmentally friendly due to its lower carbon emissions.
But heavy lobbying from the car industry in Westminster and Brussels has staved off firm action. European emissions tests for diesel cars have been far easier to manipulate than in the US; as a result, 97% of modern diesel cars exceed the official limit for NOx pollution. Behind the scenes, the British government has tried to block tougher testing. It’s a familiar story: the government similarly watered down plans to tackle childhood obesity in the face of special pleading from the food and drink industry.
The high court ruling puts the ball back in the government’s court. It should choose to accept it, rather than appeal. But either way, it has been exposed as a government willing to privilege marginal political advantage and the lobbying efforts of big business over the health of the nation.
The stiff upper lip has been declared overrated by those who are supposed, traditionally, most ardently to uphold it: the royal family, or at any rate the junior members thereof. Speaking about mental health to the charity Campaign Against Living Miserably, the Duke of Cambridge declared that “There may be a time and a place for the ‘stiff upper lip’, but not at the expense of your health.” Prince Harry, too, has told of the damage caused to his own psyche by years of “shutting down my emotions”, culminating in two years of “total chaos”.
The paradox is that the great traumatic event of the princes’ childhoods, the one that caused Prince Harry’s emotional shutdown, was often seen as marking the end of an era of British repression, as tearful mourners lined the streets for the funeral cortege of the princes’ mother and the gates of Kensington Palace were heaped with bouquets. Now lips unstiffen at the faintest provocation, it seems. Judges weep, journalists weep and contestants in TV cookery competitions weep at the drop of a hat.
The stiff upper lip, in truth, may never have been as persistent and fundamental a part of British emotional life as it has been cracked up to be, and its high watermark was probably the first half of the 20th century, when a no-blubbing rule was one way (at least in the short term) to deal with the demands of an empire and fighting two world wars. But the very fact that lips have been seen as requiring cementing into position suggests that they have had, all along, a propensity to wobble – and that what Robert Burton called “excrementitious humours of the third concoction” have always had a habit of falling. The novels of Charles Dickens brim with tears, and have always elicited them – even when certain scenes, such as Little Nell’s deathbed, may also have provoked a snigger from wits such as Oscar Wilde. The grim, uncomplaining work ethic associated with 19th-century, nonconformist, manufacturing Britain may not have favoured snivellers, but there were still mass emotional outbursts – such as the passionate expressions of religious feeling that accompanied the early Primitive Methodist gatherings.
The greatest works of literature, after all, tell us that real men and women cry. The Odyssey is deeply soaked in tears: when the reader meets the poem’s hero, longing for home, he is sitting on a headland “weeping there as always / wrenching his heart with sobs and groans and anguish / gazing out over the barren sea through blinding tears”. In the words of Virgil in the Aeneid (and in Robert Fagles’s translation): “sunt lacrimae rerum” – the world is a world of tears.
The headlines are all about the money. The NHS England boss Simon Stevens’ progress report, published on Friday at roughly the halfway point of his strategy document, the Five Year Forward View, consists of 75 pages studded with cuts in a bid to show that his organisation is not the basket case that the prime minister, Theresa May, is said to believe it is.
Hospitals throughout England are to be asked to free up 2,000 to 3,000 beds to improve the flow of patients needing urgent or emergency care. It will be done by abandoning waiting time targets for the kind of procedures, like new hips and knees, that fill the elective surgery lists. The clinical evidence in favour of some surgical interventions is to be carefully re-examined: that may mean not offering some operations at all. GPs are being asked to stop prescribing common medication that can be bought over the counter. Here is the evidence that the NHS, in an era of unprecedented financial pressure, is trying to manage on a budget that, although it has been broadly protected so far, is in fact unsustainable. Two-thirds of NHS trusts and foundation trusts were in deficit last year; by the end of this parliament, spending as a share of GDP – at 8.5%, already below the average of the 15 richest countries in Europe – is expected to fall further behind.
But after an unedifying exchange at the start of this year between Mr Stevens and Mrs May about the increase in NHS spending over at parliament (she said £10bn, he said £8bn – he is right), the NHS England boss wants to send a quite different message to government. The “Next Steps” document acknowledges the financial pressures, but describes a system in transformation that is broadly succeeding in delivering more for less in every priority area from cancer to mental health. It highlights progress towards restructuring health provision by area, integrating health and social care, and tackling bottlenecks in hospital discharges through bottom-up, locally led coordination in so-called sustainability and transformation plans (STPs). Making this work, so that demand for costly hospital care is reduced, was central to the original vision of the forward view.
Since this is the NHS, reform is never easy. Supporters of change, like NHS workers in Dorset, say their incentive is better patient care. Critics say it’s just about saving money. The recent budget included £325m to help the first nine STPs get off the ground and the autumn budget is expected to bring more of the same; not enough to stop the closure of much-loved, politically sensitive maternity units and cottage hospitals. The process of change is already slow and tentative. Protest slows it further, and reduces popular support for it. And, as the Nuffield health thinktank argues, the recruitment crisis for both GPs and district nurses is adding to the difficulties of keeping vulnerable people out of hospital.
The second challenge is a huge own goal made by the Conservatives: the Lansley reforms brought in by the 2012 Health and Social Care Act, which imposed mandatory open competition for all new contracts for services. Mr Stevens sees the sustainability and transformation plans as a way of getting round the fragmented and often failing structures that are now obstacles in the path of joining up different services. But there’s talk of legal challenge from private sector providers, such as VirginCare. The logical course of action is to repeal the act. Mrs May, as a new prime minister, could get away with it. If the STPs deliver the improvements that their advocates believe they will, then a new parliament could declare the act – and many of the reforms of the past 30 years, stretching back to Ken Clarke’s introduction of the internal market – a blind alley. Meanwhile, Mr Stevens can only hope he has persuaded Mrs May and Mr Hammond that NHS England is not a bottomless pit for precious taxpayers’ money, but a flexible, efficient organisation that is worth the big cash injection it desperately needs.
When justice is done, we should be glad. But the champagne-swigging jubilation that greeted the reduction of “Marine A” Alexander Blackman’s murder conviction to manslaughter on the grounds of diminished responsibility, went far beyond the acknowledgment that this was an appropriate outcome. To many of his supporters he is a “hero soldier” persecuted for shooting dead an injured Taliban fighter in Afghanistan. The judgment, however, was no exoneration: he killed a defenceless man, tried to make sure it was not witnessed, and attempted to cover up what he did. The judges considered mitigating factors, including his combat stress disorder. Nonetheless, they concluded that his crime was a severe one, that he held substantial responsibility for it, and that his dismissal from service was justified.
Drum-beating coverage of “our brave boys” veils the fact that British troops, like any others, are capable of terrible violations of the laws of war and the dictates of basic decency. Perhaps the catastrophe of Iraq, and the consciousness of the toll it took overwhelmingly on Iraqi civilians but also on coalition forces, has sensitised the public to the immense pressures facing soldiers and the often limited support they receive. More often than not, such abuses occur when there is an absence or failure of leadership. Another marine – briefly Blackman’s commanding officer – described the leadership and oversight in place as shockingly bad, and insisted he was not a single rotten apple. The answer is not to give soldiers a free pass to abuse and kill by attacking attempts to hold them to account, but to ask who else is responsible and how such behaviour can be prevented in future.
Blackman knowingly broke the rules of war (“I just broke the Geneva convention,” he told comrades). These are not a matter of etiquette, but morality; not a luxury, but a necessity. It is precisely because of the extremity of the situation, and the pressures upon troops, that clear rules are needed. They protect both civilians and soldiers. It took more than a century of campaigning to establish such standards. That they have often been ignored is a reason to uphold them vigorously, not to lower them.
It is not only that the end cannot justify the means. Believing that it can often leads to a different end, whether on the soil of Afghanistan or in the skies over Mosul. The fight against Islamic State there has seen a frightening acceleration of civilian casualties. Too many Iraqis and Syrians are dying in coalition strikes that are supposed to save them; and that fact, besides causing untold tragedy, is likely to fuel future radicalisation.
The increase in deaths began in the last weeks of the Obama administration – around the time that procedures were changed to make calling in strikes easier – but has gathered pace. It may reflect a tactical change in response to the heavy punishment that Iraqi forces took as they reclaimed eastern Mosul; and, around Raqqa, perhaps poor on-the-ground intelligence. But many fear that the Trump administration’s announcement of a review of the rules of engagement has been enough to lower the threshold in reality.
Western intervention in recent wars has been couched largely in moral terms. Intentions are not enough. Blackman told the fighter he killed: “It’s nothing you wouldn’t do to us.” But being better than the Taliban, let alone Isis, is no kind of baseline.
“Just how easy is it to speak about things that have gone wrong?”, asked health secretary Jeremy Hunt in a speech he made last year about improving transparency and ending the blame culture in the NHS. Mr Hunt is himself failing badly on this critical benchmark for greater openness. The Guardian this week has revealed that half a million pieces of medical correspondence, including test results and diagnoses for life-threatening conditions like cancer, sat undelivered in a warehouse between 2011 and 2016. Yet it has taken almost a year for the full extent of this failure to emerge.
Mr Hunt was first made aware of the problem in March last year. But he did not inform MPs until July last year, in a 138-word written statement that mentioned neither the scale of the problem nor the potential harm to patients. The incident was confined to a single paragraph buried in the Department of Health’s annual report. While it appears a team was set up in early summer 2016 to look into the problem, much of the undelivered correspondence did not arrive at the GP surgeries of affected patients until November and December last year. No explanation has been offered for why it has taken nine months from Mr Hunt being informed to urgent correspondence finding its way to patients and their doctors. The idea that letters containing test results and diagnoses for life-threatening conditions can go missing for years is a frightening prospect for any NHS patient. According to the government, 500 patients may have suffered serious harm as a result of the missing correspondence.
The way that Mr Hunt and his department have handled this affair seriously undermines his pitch to be an ardent advocate for patient safety. It bears all the hallmarks of a government whose primary concern is not the health of NHS patients, but sneaking out bad news in order to avoid an embarrassing story. Mr Hunt has rightly drawn lessons for the NHS from the airline industry, which radically improved its safety record by improving transparency. He has introduced grading of hospitals on the openness and honesty of their reporting cultures. But he has failed utterly to hold his own department to the standards he expects of hospitals.
It is critical that affected patients are swiftly identified and offered an apology and financial compensation. But patients who have suffered as a result of NHS mistreatment often say that what’s more important is knowing what’s happened to them will never be allowed to happen to others again. This means tough questions need to be asked within Mr Hunt’s department about what went wrong, and what needs to change. How could such a monumental failing go unnoticed by so many for so long? How could the Department of Health fail to hold the responsible private company – which it part owns – accountable for basic standards like the successful delivery of internal correspondence?
These issues will remain relevant when and if the NHS ever completes its much-delayed transition to digital patient records. Mr Hunt said he wanted the NHS to become paperless by 2018; that goal now looks a long way off. There is nothing to suggest a paperless NHS means a more competent NHS when it comes to communicating with patients and updating their records. NHS IT projects have a terrible track record: the last ill-fated attempt to create electronic patient records was abandoned after nearly £10bn had already been spent on it. The creaking IT infrastructure at many hospital trusts has resulted in several serious data failings, including at St George’s in London and the Leeds Teaching Hospitals Trust, often resulting in cancelled operations.
Communications and IT failures are far from the only risk to patient safety. The current NHS funding crisis has crippled the finances of many hospitals, leaving them with staffing levels that fall far below those recommended as safe by the inquiry into the devastating failures at Mid Staffs. Indeed, its chair, Sir Robert Francis, has warned the NHS now faces an “existential crisis” that makes another scandal on this scale inevitable.
Mr Hunt is perhaps the first health secretary to put patient safety so firmly at the heart of his rhetoric. But rhetoric cannot save patient lives. This week’s revelations of cover-up could not run more counter to his agenda to improve transparency in the NHS to reduce avoidable deaths. Mr Hunt must reflect on why – far from modelling the culture he expects from hospitals – he and his department have so badly failed to practise what he preaches.
Another week, another dreadful story about patients suffering at the hands of our increasingly cash-strapped NHS and care system. This time it was Iris Sibley, an 89-year-old woman kept isolated on a hospital ward for six months, despite being well enough to be discharged, because of a failure to find a suitable nursing home place. The result: not just huge financial expense for the NHS, but great human cost in distress and anxiety for Iris and her family.
The NHS’s alarm bells have been trilling furiously for months. Nine out of 10 hospital trusts have experienced overcrowding this winter, and the number of people facing long waits of more than 18 weeks for routine – often pain-relieving – care, has doubled in the last four years. Cynics are deploying the NHS’s current woes to argue the cherished principle at its heart – free care at the point of delivery based not on ability to pay, but on clinical need – makes for inefficient and unsustainable healthcare. Nothing could be further from the truth: one study rated it the top-performing healthcare system out of a group of countries that included Germany, France and Canada, despite costing less per head than all but one in that group.
What we are seeing is the direct result of our health service being starved of the financial resources it needs to maintain existing levels of care to an ageing population. The government has imposed the tightest funding squeeze the NHS has faced in its 70-year history. Little surprise, then, that hospital trusts in England ended the year with a record deficit triple the size of the previous year’s. The NHS’s problems have been compounded by cuts to social care: council spending on social care has fallen by 11% on average since 2010. Less state spending on social care means older people languishing on hospital wards when they are fit to be discharged, at great damage to their physical and mental health, and to NHS finances. More cash is not the only ingredient needed for the delivery of world-class care.
The NHS needs reform and modernisation to respond to changing needs, with more care delivered in the community for people living with long-term conditions, and more specialist acute care delivered in bigger centres. But deliberately depriving the NHS of the resources it needs makes this even more difficult. Local NHS leaders in England have been charged with transforming the delivery of care in their areas over the next five years to make it fit for the future. There are examples of real innovation, such as Manchester’s ambitious efforts to bring together health and social care in one budget. Yet, forced to find immediate savings, the process has inevitably become more about cutting back than about modernisation.
The government’s response has been shameful. Health secretary Jeremy Hunt continues to insist the English NHS has been given the resources it asked for, despite the health select committee pointing out the dodgy financial engineering involved in this claim. Even worse, he has sought to deflect from the funding crisis by launching an offensive against overseas patients, despite the fact that pre-charging them for elective care would raise only a tiny sliver of the NHS’s annual budget. This dog-whistle politics is all the more revolting given the NHS’s reliance on its migrant workforce.
There is a growing consensus our health and care systems urgently need more cash to see them through the next few years. Those calls are not being heard by a prime minister who warily regards the NHS as a bottomless drain on resources, and has prioritised tax cuts for businesses and more affluent families over spending on public services. Yet public affection for the NHS leaves ample room for leeway: back in 2002, Gordon Brown achieved the unthinkable – a popular tax rise – to boost health spending. Recent polling shows more than half of the public would be prepared to pay more tax if it were earmarked for the NHS. Mrs May should take a leaf out of her predecessor’s book.
No one, ever, wants to talk about remote, unglamorous, local government funding. As long as the bins are emptied, most fit adults put up with the closure of the local library or reduced hours at the leisure centre as a sad but minor inconvenience. It is time to take a refresher course.
What and how councils were funded was settled with a sigh of relief audible around the country after Margaret Thatcher was destroyed by the poll tax in 1990. Now the results of these decades of political neglect are in the headlines – but only because the cash crisis in locally funded social care is a major contributor to the crisis in the NHS. Local government finance is a long way from the point where it is threatening a prime minister. But that doesn’t mean it can’t happen again.
Councils’ income comes mainly in Whitehall grant. Much of it is tied to particular budgets like schools, or pothole repair. In various permutations, it also comes from the regressive council and business taxes that are based on property values not disposable income. Since 2010, increases in council tax have been capped at 2%, unless a local referendum authorises a rise. At the same time, central government has cut its grant to councils by more than 25%. Last month, the communities secretary, Sajid Javid, confirmed the budget for the coming year; now the local government association has crunched the numbers. It warns that by 2020 there will be a shortfall in cash of nearly £6bn. On the ground, that represents further and deeper cuts in every department. In particular it means further pressure on adult social care. There’s too little money for services that help people stay at home; care homes are shutting or going bust, and vulnerable elderly people are forced to move. And it means more hospital beds occupied by people who’d like to get out, but have nowhere to go. Last week Surrey, a Tory heartland, announced one radical answer: a referendum on raising council tax by 15%. In leafy Surrey, that will generate an extra £90m a year. But in Liverpool, where a 10% increase has been considered, it would bring in barely a third of that.
Things have to change. In health and social care, no policy maker can make rational decisions when social care is paid for by the client or the council while the NHS is free at the point of use. Every sensible reform starts with pooled local health and care budgets. The NHS’s programme of individual sustainable transformation plans being prepared district by district may be one way of working out how to do this, but they are likely to come with an unpopular bill in terms of reforms of wider NHS provision.
Health spending, however, is only one part of what is needed. The northern powerhouse, which in effect devolves industrial strategy, may evolve into a model for other local government organisation. Its advantage is not only that it can tailor policies in education and skills training, infrastructure development and housing to meet its particular needs but, by growing the local economy, it can also increase the region’s tax take. For the question at the heart of the dilemma is how to fund local government in a way that is both sustainable and locally accountable. As LSE’s local finance wizard Tony Travers put it, we cannot go on running Swedish-style services on a US-style tax system. We have to choose.
Most people would like to live in a society that is fair, where merit is rewarded and every child in every part of the country has a similar chance of health and happiness. Most of us recognise that however much successive governments declare their intention of working towards this ambition, the goal gets no nearer. Austerity has fallen unequally. The number of children in poverty, which fell by a third in the decade after 2000, is now expected to be back above 3 million by 2020. A new report from Professor Neena Modi, president of the Royal College of Paediatrics and Child Health, shows poverty and inequality wrecking health. New analysis of university entrants suggests that black and minority ethnic applicants still struggle to get into Russell Group universities. And Alan Milburn’s social mobility commission has done groundbreaking research showing that working-class kids who leap all the barriers and make it in to the top professions still don’t get on as fast or earn as much as their more privileged peers. It adds up to a world in which disadvantage is becoming entrenched.
Since 2010, policymakers have been thinking less about poverty than about social mobility. Others see life chances, the possibilities open to every citizen from cradle to grave, as the best way of measuring progress. These distinctions of terminology matter: they shape the way we think about the answers. But none of them seems quite complete on its own. There is a clear link between low-income families and the appeal of cheap, filling food that tends to lead obesity and the kind of outcomes Professor Modi describes, where Britain’s level of infant and child mortality is among the worst in western Europe. But it doesn’t account for the level of smoking in pregnancy – three times higher in Northern Ireland than in Lithuania, where the per capita income is only a fraction of the UK’s, or why babies in Norway are twice as likely to be breastfed as they are in Britain.
And at the other end of the scale, it certainly isn’t poverty that accounts for the findings in the latest report from the social mobility commission which suggest that if you come from a working-class background, with parents in routine or semi-routine manual work, you are much less likely to get a job in the so-called senior professions of medicine or academia; a contemporary from a professional or managerial background is 2.5 times more likely to be taken on. You are also much less likely to be in the top income bracket. According to the report, professionals in, say, law (and journalism) who come from working-class backgrounds earn more than £2,000 a year less than their peers from professional backgrounds. The report’s authors think they have identified a “class ceiling”.
If it is not only merit that brings success even in areas of work that appear to be all about brains, it is clear that something else is in play. Politics hasn’t had much to say about class and social policy since the early 1990s. It didn’t fit with new Labour being relaxed about the filthy rich. The silence has allowed practices that are indirectly discriminatory – such as computerised application forms that weight educational background as well as achievement, for example – to become embedded; it has legitimised the unpaid internships and the networks that filter out the less well connected. It is beginning to look as if class belongs right back in the political mix.
Philip Hammond threatened in his interview with the German newspaper Welt am Sonntag to turn Britain into a low-tax offshore sweatshop, although he expressed a personal preference for a European model of social organisation. Just how distant his preference is from his threats is clear from some recent developments in Europe: the French have passed a law limiting the use of email out of hours; the Dutch and Finns are thinking about a universal basic income, and in Sweden the city of Gothenburg is evaluating an experiment that allowed care workers in an old people’s home to work six-hour shifts instead of eight-hour ones for the same full-time pay and benefits.
The idea has been tried on a small scale elsewhere in Sweden many times over the last 10 years, but almost always at “creative” or desk-based jobs. Dedicated physical work, as is involved in a care home, seems an entirely different category. Successive scandals at Amazon, Sports Direct, and similar places have accustomed us to the idea that a modern economy is distinguished by the most sophisticated possible exploitation of the workers who actually move things (or even humans) around by those who manipulate algorithms and exhort the rest of us to productivity.
The Swedish experiments suggest that there is a better way, and a better perspective to think about this than simply productivity, narrowly considered. They represent more than a victory for unionised labour and its allies in the endless struggle against capital. At the moment the experiment is justified on the grounds that the workers who had to work less felt less stressed and reported sick less often. They would, wouldn’t they? It still cost their employers extra money to replace them, and it’s not clear that there is the political will, in Sweden or elsewhere, for taxpayers to contribute further to the wellbeing of council employees. But there are other ways to look at the matter, starting with asking: what is the purpose of work?
The question worth asking is not whether shorter hours made the workers feel better, but whether it caused them to do their jobs better. In the case of creative industries, the answer is obvious, and to some extent measurable: there really is a limit to the amount of time that can productively be spent on sustained intellectual effort every day. Once that is exceeded, more work produces less worthwhile product. Some of the things necessary to fill a long working day, like meetings and email, actually erode the capacity to produce anything valuable. This isn’t surprising. Professional athletes have to be careful not to overtrain. Why not professional athletes of the mind and the imagination? Teachers and social workers burn out. There need be no shame in this: people are not machines, and work that demands inner resources demands also that they be given time to be replenished.
But care work, too, makes demands on the intellect, the emotions, and the capacity for attentiveness, which are hard to measure but go far beyond the physical. Anyone who has looked after small children understands this and knows that it would be almost impossible to keep up periods of intense engagement for as much as eight hours. Old people are not less demanding, deserving, or less in need of attention. If they are propped up in front of a television screen and left to vegetate for hours this isn’t productivity but institutionalised meanness and indifference.
In practice, and by long, bad tradition, every kind of health work is associated with crushingly long hours. The doctor on call and the A&E nurse can both work to the point of impaired judgment far beyond exhaustion, sustained only by the knowledge that they are desperately needed. In this country, at the moment, we can hope for no more than a very slight amelioration of these conditions. But the European experiments suggest that there might be a radically different and better way in some other future far from Brexit Britain.
The news that two healthcare trusts in London are to experiment with a system to look up symptoms by text message, to triage the kind of non-urgent queries at present handled by the NHS 111 service, raises many questions. They may not seem urgent when people are dying in the corridors of an NHS hospital for want of money, but in the long term they are just as important. Some are purely medical: is this an area that requires the attention of a human being, or is it one where purely factual answers will suffice? When will this project start using artificial intelligence? Some have to do with the way that the NHS is being privatised around the edges in ways that disadvantage the central public parts of it. Widest of all is the general question of the automation of brainwork, which might have effects quite as gigantic as the replacement of manual labour by technology has had.
Two kinds of claims are made for AI in medicine. The weaker and more plausible is that it can automate the processes where no judgment is required, only the clear and consistent following of well-understood rules. This kind of thing is what the 111 service is supposed to do: the question that it answers is not “what’s wrong with you?” but “do you really need to see a doctor?” Some triage is necessary in any healthcare system, and the present system in the NHS is under huge and growing strain.
But the wider claim of healthcare automation is that there will be systems that can augment and eventually replace the judgment of trained human beings. The hope is that deep analysis of unimaginable quantities of data will yield reliable knowledge superior to anything that unaided humans can produce. The placebo effect is important in medicine, and people who believe they are being treated by doctors who have the help of almost omniscient computers will probably do better than those who feel they are getting the harassed attention of an overworked GP even when the diagnosis and the remedies prescribed are exactly the same, as in most cases they will be. But that is not the basis on which we are promised a revolution in the delivery of healthcare. The revolution may come anyway: we are living through an enormous expansion in the reach and variety of machine learning systems, but it will not be for some time. The great majority of diseases do not require heroic diagnosis and exceptional treatment so much as the humane application of well-understood treatments. Much of what’s wrong with the NHS is a lack of money rather than sophistication. Even urgent large-scale threats such as the emergence of antibiotic-resistant pathogens don’t need artificial intelligence to avert, only the consistent use of the intelligence we already have.
It is the apparently small-scale automation of clerical work that we need to think about, because that might happen as quickly as the spread of smartphones did. Vast areas of bureaucracy are about the reduction of complex problems to simple ones for which the correct answers can be written down in a flow chart. This is artificial stupidity rather than artificial intelligence, but the two can merge inside computer systems to produce huge social change. Once the work has been broken down into simple algorithms, these can much more easily and quickly be followed by machines. The 111 service in north London is only one example of a much wider phenomenon. A Japanese insurance company has just replaced 35 claims processors with IBM’s Watson expert system. The Japanese government is preparing to automate the responses to parliamentary questions in a similar way. These are the first signs of a process that may annihilate millions of white-collar jobs in the same way that blue-collar jobs have already disappeared across the developed world. That would be a development to make last year’s political upheavals look like the mere premonitory tremblings of a real earthquake to come.
“Quite often people are in hospital and they’ve got nothing: no food, no clothes, no toiletries,” says Kate Gillespie, Derventio Housing Trust’s strategic lead for its Healthy Futures initiative. “We get all that sorted out, so people at least have a bit of dignity when they are discharged.”
That’s just the start of the scheme’s work with homeless people due to leave hospital. Many have multiple, complex needs, such as mental health problems and addictions, and are trapped in a vicious cycle of ongoing health issues and repeat admissions.
Over a 12-week period, staff work intensively to find housing for patients, settle them into their new homes and help them live independently – while making better use of primary care, rather than relying disproportionately on acute services.
“Sometimes it’s because they don’t manage their health, so they actually get ill enough to need to go in [to hospital] all of those times,” Gillespie says. “We’ve also got people who are going in because it’s their social contact. They’re so isolated that the only kind of love and nurture they get is a trip to A&E, where they get a sandwich and a cup of tea and a ‘there, there’ from the nurses. When someone has nothing else they’re going to keep coming back for it.
“It’s like they’ve got a dependency on acute care. We transfer that dependency to us, and then take the time to wean them off it. If we get someone who’s in A&E three times a week, the next step down from that is a walk-in centre. Then their GP, then the pharmacy.”
Healthy Futures, which also offers brief interventions to help with the timely discharge of inpatients with less complex housing and support needs, has worked with more than 330 patients since it began in October 2013. Some 170 patients have received ongoing community-based support.
In the six months before becoming Healthy Futures clients, those patients had been admitted to acute beds on 487 occasions, had gone to A&E 616 times, and had called 999 and been taken there by an ambulance 364 times.
The project has led to an 88% fall in avoidable admissions of clients, a 90% drop in clients’ visits to A&E, and 84% fewer 999 ambulance transfers. Hospital stays have also been cut by an average of 16 days. Two thirds of patients felt their physical health had improved, and the same proportion reported better mental health.
Healthy Futures’ achievements come despite working in a climate of cuts to adult social care, at a time when finding housing is harder than ever. Key to getting funding has been its use of robust data proving its impact and efficiency. Patients give consent for their health records to be accessed, so their use of acute care before working with the project can be tracked – and commissioners can clearly see the positive effect.
Great staff are also vital, Gillespie says. “They’re just amazingly capable and patient and resourceful. I’m immensely proud of them.”
As a matter of good administrative practice, it makes sense to charge non-UK residents for non-urgent health treatment (there is no suggestion that anyone in urgent need would be turned away). Reclaiming patients’ costs from other European countries, under the existing reciprocal arrangement, is also sensible. But doing it in a system like the NHS that is predicated on the principle of providing treatment free at the point of use is complex, expensive and, as a Department of Health briefing paper released last winter shows, scarcely cost-effective. The trouble is that the target of a seven-fold increase in what is reclaimed, which is estimated to raise the total from £73m to £500m, has been factored in to NHS England budgets.
It is the question of how to achieve it that led the senior official at the Department of Health, Chris Wormald, to tell MPs on Monday that it might involve requiring all patients to produce their passports. As Mr Wormald readily admitted, that is a course of action fraught with difficulty. It might do more harm, by putting off people in need of treatment for the public good as well as their own, than it saves money; and although for individual budget-holding trusts it may be important – which is why trials are under way in the Stamford and Peterborough area – in the context of NHS England’s annual budget of £120bn, it is a very small drop. That point was underlined by the coincidence that, as Mr Wormald was talking to MPs, the National Audit Office was releasing its latest bleak assessment of the financial sustainability of NHS England. It showed that at the end of the last financial year, more than two-thirds of trusts were in deficit, and it concluded that its financial problems are endemic and not sustainable.
This is not a piece of gratuitous shroud-waving on the eve of Wednesday’s autumn statement. The NAO is the nation’s accountant, and its audits are based on scrupulous analysis. But nor is it necessarily the right answer for the chancellor, Philip Hammond, to reach immediately for extra cash for hospitals. His predecessor, George Osborne, might have seen tackling the headline as the priority, but ever since Theresa May became prime minister the message of no more money (often framed in the context of the deep cuts that have been survived by Home Office dependents such as the police) has been unmistakable. The Department of Health’s defence is that it has given the NHS England boss, Simon Stevens, just what he asked for in the Five Year Forward view – which committed the NHS to heroic and probably unachievable savings in return for front-loaded extra money.
Ministers’ arguments have been vitiated by a Nuffield Trust analysis which suggested the billions promised were worth just £800m in real money. More important is that it also ignores the role of council-provided social care that Mr Stevens said was integral to the success of his plan. Social care budgets have been brutally shrunk. A million people are not getting support to stay at home, with the predictable consequence that many stay in hospital when they no longer need to. It is hinted that councils may be allowed to raise the ringfenced precept that they put on council tax for social care: but that would, on King’s Fund numbers, raise at most £388m. The estimated shortfall next year is £1.9bn. Paradoxically, that means the best help for hospitals may be extra cash not for them, but for councils.
Across England and Wales 140,000 miles of tidy and scrappy, rough and smooth and muddy, open, wooded, exposed, sheltered, peaceful and exhilarating rights of way roll and ramble across some of the two nations’ finest landscapes. They meander from pub to hamlet and farm to school, or sometimes just from suburb to suburb by the scenic route. Now, over a little more than a year and helped by more than 3,000 citizen’s surveys, Ramblers (formerly the Ramblers’ Association) has mapped the condition of enough of these sometimes ancient routes to conclude that more than half are in a good condition, treasured, enjoyed, and as well maintained as a vital part of the common interest should be.
But the picture is uneven. Where the landowner is the National Trust, the National Forest or a national park, the story is usually good – streams with stepping stones, fences with working gates. But as many as a tenth are in serious disrepair: unsignposted, overhung by inhospitable brambles and thick with threatening nettles. That is 14,000 miles of rambling that hovers between the difficult and the impassable. No surprise that these paths are often in areas where local councils, responsible for maintaining rights of way, have experienced the worst cuts. How obvious it must seem, when faced with the choice between closing a day centre or maintaining 100 miles of footpaths, to let the axe fall first on what seems inessential.
Yet, as the Ramblers point out, walking is probably the best single way of promoting both physical and mental health yet to be devised. If everyone walked for two and a half hours a week, fewer people would need doctors and the NHS could be nearly £2bn better off. It is something that almost everyone can do. No special equipment is needed – just paths there to walk on, safe, traffic-free and easy to reach. There is even a budget, just not the obvious one. Under the largely destructive Health and Social Care Act of 2012, responsibility for public health was devolved to local councils. There are some obligations they must fill, relating to the provision of access to such things as sexual health services and baby and child health measures. But there is scope for local interpretation too, to chose what form of public healthcare local people will get the most benefit from. Some things – stop-smoking and substance abuse programmes – are usually essential. But walking, along with facilities like green spaces and play areas, could be part of the programme too.
Unfortunately, the Treasury view does not encompass public health; if extra cash for the NHS has to be found, it is invariably the public health budget that is raided. So, after the last election, £200m was taken out mid-year. Earlier this year, it was announced that the budget, now at £3.38bn, would shrink again, by just short of 4% a year until 2020. The sub-budget for promoting physical activity, King’s Fund research found, has now been cut by nearly 15%.
MPs on the communities and local government committee have just launched an inquiry into the state of parks in England. They are hearing bleak messages about play areas closed because councils can no longer afford to maintain them and about park wardens, who kept spaces safe, made redundant. To that toll can now be added thousands of miles of rights of way that, like parks and play areas, should be playing their part in keeping the NHS solvent by making us all healthier.
Philip Hammond may always have dreamed of becoming chancellor, but it is unlikely he imagined it would be in such difficult and uncertain times. The impact of the fall in the value of sterling is only the most obvious of the complexities he has to juggle as he prepares for his first set-piece moment, next week’s autumn statement. The clamour from public services for an emergency cash injection after six years of savage austerity has never been louder. Benefits, further education colleges, and perhaps most consequential, social care have all felt the pain as council spending was cut by £18bn – about a fifth – in the coalition years, and is now facing cuts of half as much again in this parliament.
Nominally, the NHS budget has been protected. But not even Conservative MPs on the Commons health committee believe the government’s headline claims. The impact of not enough money for hospitals and access to care are written for all to see in rising demand for A&E and missed waiting times, where – according to the Health Service Journal – all surgical specialties are now in breach of the 18-week target for the wait between referral and treatment. There are complex reasons underlying the figures, but the consequences of bed-blocking are one of the most important. In September, the last month for which data has been released, 192,000 days were lost by delayed transfer of care. Some NHS number-crunchers believe the real number of people in hospital who should be being cared for in the community is probably four times as many as represented by those figures.
There is now an unprecedented level of agreement that social care should be at the very top of the list of Mr Hammond’s priorities for urgent extra funding. The triple whammy of shrinking budgets, rising demand and the cost of paying the (long-overdue) national living wage to care workers has left many councils paring their help for the elderly back to the barest minimum. Between 2009 and 2013, there was a 26% cut in the number receiving support in their homes, leaving a million people without the care they needed, and the situation has only worsened since: on some calculations £4.6bn was cut from care budgets between 2010 and 2016. Last month the Care Quality Commission warned that services were at a tipping point. The Local Government Association, representing more than 300 councils in England and Wales, says the situation is perilous. Charities, Tory MPs in public, and it is understood the health secretary, Jeremy Hunt, and the communities and local government secretary, Sajid Javid, in private, are all arguing for extra cash before winter starts to bite.
Mr Hammond is said to be considering a plan to release more cash in April, or to allow councils to raise council taxes. Both plans may be needed. But the crisis in hospitals provoked by the shortage of community support for older people is likely to peak long before the spring, while raising council tax brings in much more in richer areas in the south-east of England than in areas where council tax receipts are smaller. Last week, for example, Liverpool’s mayor, Joe Anderson, proposed that to avoid to avoid cuts of 50% across the board, there should be a vote on a 10% increase in council tax. This is the dilemma facing us all, not just Liverpool. Higher taxes, or shrinking services.
Do you look at other people’s lives and compare them to your own? Does this make you question whether you are smart, fit or happy enough?
If so, then you may be a perfectionist. Writing for the Guardian earlier this year, clinical psychologist Linda Blair described a perfectionist as a person: “who strives for flawlessness, for a perfect creation, outcome or performance … They find it difficult to delegate, even if that means neglecting their health, relationships and wellbeing in pursuit of a ‘perfect’ outcome.”
According to some studies, this is something that largely affects women. A US survey in 2009 found that women are also more likely than men to experience feelings of inadequacy at home and at work, and a larger proportion felt they failed to meet their own high standards.
These insecurities are well-documented in the world of work: in 2011, the Institute of Leadership and Management found half of female managers, compared with fewer than a third of the male ones, reported self-doubt in their performance. An internal survey of women working at Hewlett-Packard also found women applied for a promotion only when they met 100% of the qualifications. Men applied when they met just 50%.
The desire to be perfect seems to influence thinking from a young age: research by Girlguiding UK found that a quarter of seven- to 10-year-old girls felt the need to be perfect.
Perfectionism can have serious implications: it’s been linked to anxiety and depression, and the health and happiness of young women is a growing concern. In fact a NHS study found 28.2% of 16- to 24-year-olds have a mental health condition, with one in four women aged 16 to 24 experiencing anxiety, depression, panic disorder, phobia or obsessive compulsive disorder.
We decided to explore this topic with our readers, asking for young women’s experiences and stories of perfectionism. We received 134 responses – with an average age of 25. For a lot of young women who contacted us, body image was a huge preoccupation and many said they felt undervalued unless they met society’s expectations of beauty. The pressure to be perfect also extended to the workplace, withmany respondents talking about feeling inadequate at their jobs or experiencing impostor syndrome. They also complained of feeling the pressure to have it all: juggling being a mother with career and other personal pressures.
Social media has a big role to play in influencing women’s outlook on this issue. Miranda, 18, from Cambridge summed this up: “I certainly feel the pressure to be perfect and it has got to the point where it’s damaging my health. Social media is the main culprit. I had to delete my Instagram account because it would actually make me cry. I am a mature person with a firm grip on reality, but I have so many peers whose lives seem so perfect and sociable that it left me feeling worthless and lonely.”
The impact of all this pressure on women’s mental health and wellbeing was notable, with many experiencing anxiety, eating disorders and depression. We approached five women to find out more. Here are their stories:
Chardine Taylor-Stone, 31, who works in the arts in London
‘The pressure to be perfect feels heightened to me as a black woman.’ Photograph: Sarah Lee for the Guardian
As a child I felt pressure to be a certain kind of perfect, so I wanted to look pretty and nice while my male cousins were running riot, that sort of nonsense. I wanted to marry a man and get a job.Now I am an adult my aspirations have changed and I am a lot more confident about who I am. I’ve broken out of those narrow expectations, but I still feel a lot of pressure in terms of my career.
I am one of few black working-class womenin my industry,which is dominated by white men. Most of the black women I see in the arts are personal assistants;none of them are working in a position that gives them autonomy – although they usually end up running a lot of things anyway.
I definitely have impostor syndrome; that’s defined as self-doubt and a sense of intellectual fraudulence thatoverrides any feelings of success. I didn’t have this so much before, when I was working in call centres, but I feel it now in a predominantly upper-middle-class environment. It’s weird being the only person of colour or the only one with a certain accent – it makes you feel as though you shouldn’tbe there. I sometimes suffer so much anxiety about sending an email, worrying about whether I will phrase it correctly. It’s silly because I’ve done well and proven myself, I have my own flat and a good job, yet that doesn’t feel good enough.
The pressure to be perfect feels heightened to me as a black woman because my mum always told me I would have to work harder than a white person to get ahead. It is true but it’s a self-defeating aspiration.
Perfection, or what society deems perfect, is not attainable for everyone, but it feels even further away for a woman of colour. The image of perfection is a certain physical type: a skinny woman with blond hair etc. Those things are not even half attainable to you, and you sometimes feel you were born imperfect.
Salma Al-Hassan, 18, student at Warwick University, from Oxford
‘I wish I could be more relaxed about how I look.’
I feel the need to look perfect all the time. I am not sure where this obsession comes from but social media definitely makes it worse.
I got Instagram when I was 14 and growing up with it has really affected me. I spend ages scrolling through the site and seeing images of women with perfect hair and makeup, thinking I should look like them – even though a lot of the time the pictures have been altered. I have always felt self-conscious about my hair because it wasn’t long and straight like the girls I saw online. I would see all my friends with their silky long hair, so easy to brush, and think: “I want that.” I got hair extensions to make my hair longer, which cost a lot but now I am trying to love my natural afro hair again. I want to embrace my natural curl.
Social media also brings the pressure of getting lots of likes; a lot of people post at “prime time”, which is about 5pm, when everyone is online. I know friends who will say: “If I don’t get 40 likes I am deleting the picture.” I’m not majorly worried about this, although I have deleted photos before, but afterwards thought: “That was stupid and I shouldn’t care what other people think.”
Another source of pressure for me, personally, comes from the fact that the media has become obsessed with a particular aesthetic for mixed-race and black women. We are only deemed attractive if we have tiny waists and large hips and lips. Over the past few months I have started to become very self-conscious about my lips, which are not as full and beautiful as other black women’s. I don’t have plans to get plastic surgery, but if I did get anything done it would be lip fillers because it just seems to be a fashion thing now – lot of celebrities get it done.
I wish I could be more relaxed about how I look: I am getting better gradually but I still always try to look good, and always put on makeup. While nowadays there is definitely a much more diverse idea of what beauty is, there are still stupid stereotypes which people are stuck in, myself included. There is still a long way to go for women to accept themselves for who they are.
Anna Robertshaw, 37, a yoga teacher from Tunbridge Wells
‘From the outside my life looked great, but inside I was struggling.’
My early 20s were a bit of a whirl. I got pregnant with my eldest at 23, which was wonderful; at the time I was still together with my husband,who was my childhood sweetheart. After our son was born we set up home in Tunbridge Wells and I quit my job to become a full-time mother. My husband had a wonderful and well-paid job and so we moved into a beautiful home, and it wasn’t long before my second son came along. Then, when he was five months old, I got pregnant with my third boy.
From the outside my life looked great, but inside I was struggling. I felt a lot of pressure to be a perfect mum, and this got worse when my boys started school. I couldn’t help but compare myself to other mothers, and to think their children were really polite and wellbehaved. I felt lost and had no confidence in my ability to raise my boys in a way that was right for me.
Depression and anxiety came on thick and fast. I was prescribed antidepressants, but I soon realised they were not for me. I remember sitting out in the garden, feeling so detached from my boys. It was like I was looking at them through a screen. I stopped medication and sought other means of help, eventually finding homeopathy and yoga.
My life took a different course after this, and I separated from my husband. Part of my recovery was letting things go, and starting to take charge of my life and think about what was right for me. For so long, I had fitted into everyone else’s idea of who I should be, and I was so afraid of breaking that image, but it was making me miserable.
With age comes wisdom and now I am happy with my new partner and my life in general. I am much less harsh on myself and have realised everything cannot be perfect all the time.
The biggest lesson for me, in terms of losing the urge to try to be perfect, was becoming a mum: it taught me that it’s not all about me, it’s all about them. Kids have their own views and sometimes speak more truth than grownups. They also taught me that I couldn’t possibly maintain a tidy, clean house all the time and neither could I maintain my body shape or appearance because of the effect being pregnant for years has had on them.
My advice to young people today would be to find a hobby or passion that brings you joy and don’t compare yourself to others. Sometimes it’s our biggest failures that teach us the most valuable lessons and letting things fall apart isn’t the end of the world – it’s a chance to rebuild it.
Lotta Sampson-Stone, 22, a student and single mother from Plymouth
‘Being a mum, in particular, is a lot of pressure.’
I am quite critical of myself as a single parent. I am conscious of trying to portray myself online and to family as the perfect mother and now I am at university I also want to be a perfect student. It can be hard to juggle everything.
I moved to Plymouth from Lancashire for universitylast yearand have been desperate to make it work, but it’s hard. I worry that I’ve not spent enough time with my daughter and too much time in the library, or that I’ve spent too much time with her and not enough time socialising.
Being a mum, in particular, is a lot of pressure. On Facebook I see mothers saying: “I baked with my boy today and we made pasta necklaces.” When you’ve just plonked your kid in front of the telly it makes you think: “Should I be doing that?” But it’s hard to be a full-time student, single parent and do baking and arts and crafts activities as well.
I made a conscious decision only very recently to limit time spent on social media. I did not want it to impact on how I viewed my life with my daughter and what I could and could not provide for her. The best thing I can give her is a mum who’s totally happy and present in the here and now – she doesn’t care that her mum isn’t a size six or that the flat gets cluttered..
I hope my daughter won’t grow up as insecure as me. I hope she never negatively compares herself to others and that if she recognises differences she embraces them and does not feel they make her less of a mother, student, woman or human being.
Kate Goodrum, 18, a student at Cambridge University, from London
‘One thing I have learned is that being perfect doesn’t always make you happy.’
Even as a girl I always had a perfectionist streak. While other children went out and got cheerfully muddy I would be held back by a fear of looking scruffy, and even in primary school I worried about not getting good grades. So the drive for perfection was always there, but as I got older it took hold in a more negative way and led to an eating disorder. I became very critical of how I looked, to the point where my body mass index got really low and I was told by doctors that I wouldn’t be able to sit my GCSEs if my health didn’t improve.
This was so hard to take because I’ve always striven for perfection, academic as well as physical. In fact, it was the wake-up call I needed and I went for treatment. By the time my A-levels came around I’d put on weight and was much better physically, but there were still underlying issues and insecurities.
Eating disorders never really go away, and even four years later, although I’m much better, I still compare myself to others and feel bad about how I look, thinking I am too fat or not tall enough and I don’t have abs.
I have sort of come to terms with the fact that being a perfectionist is part of my personality. I’m never content with anything I have achieved. I got into Cambridge University last year and while I am excited about starting I am also worried about the workload. I hate not being the best at everything and I worry I will be the dumb one there as other people will be so clever and multi-talented. I am worried I won’t be able to keep up.
Despite this, all I’ve experienced has taught me to try to be less harsh on myself. One thing I have learned is that being perfect doesn’t always make you happy. You can have a great body and do well in exams but it doesn’t solve all your problems – even my response to getting into Cambridge has made me see that.
In my mind the perfect woman is successful, happy and not stressed. Someone with a good social life and lots of friends. I suppose someone who has everything really, but then the older I get the more I realise that this ideal probably doesn’t exist. Maybe it’s time we stopped striving for something else and started celebrating what we have now.
No one who has experienced adult social care – whether as patient or provider – will have been surprised by the Care Quality Commission’s verdict this week that cuts to local authority services had reached a “tipping point”, with grave consequences for the NHS. Council-run care services were not included in the Treasury “ringfence” around health spending. Since local authorities face cumulative budget cuts of up to 40%, much of the burden of looking after elderly people is transferred to hospitals. Elderly inpatients, many of whom should be discharged for treatment at home, then “block” beds on wards. There is nothing sustainable or conscionable about a system that treats the elderly as a liability to be shunted around an unfathomably complex system.
For that reason a consensus in policy circles has emerged around the idea that NHS and social care services should be merged. But there is no agreed method. One attempt to integrate a range of national services in eastern England failed last year in the ninth month of a five-year contract worth £800m. The National Audit Office blamed failure to anticipate demand on services, underestimated costs, and structures that meant patient accountability slipped through gaps between commissioners and outsourced providers of care. Many people do not realise that social care is a labyrinth of NHS, local government and private-sector provision until they are lost in the maze. And ministers have shied away from confronting voters with painful truths about cost. A cap on the amount any individual should expect to pay, originally due this year, has been deferred to 2020. Even then, the cap will not include bed and board, so residential care will quickly consume the savings of those who do not pass a stringent means test.
The government has tried to divert a few extra resources towards this cinderella service, but there has been nothing to match the scale of the challenge, which grows as society ages. The number of citizens over 85 will double within a generation. A first step towards grappling with the crisis involves setting aside tribal party hostilities. When the last Labour government considered a levy on inheritance to fund social care, the Tories cynically denounced the measure as a gruesome “death tax”. Labour’s preference in opposition for impugning the motives of Conservatives – as if they are incapable of compassion – hasn’t raised the tone of debate.
Politicians will have to decommission these old rhetorical weapons. The left will have to accept that Conservatives who see a role for the private sector in reforms are not driven by evil intent to denude the public realm of assets. The right must concede that Labour looks at taxes not because it relishes confiscation from the middle classes, but because taxation might be the best way for a society to pool resources in the collective interest. As Theresa May told the party faithful, tax is “the price we pay for living in a civilised society”. A crisis of this order transcends party allegiance. Social care and the NHS will have to be better integrated. Any feasible solution will involve a mix of public and private provision, coupled with public funding through higher taxes. Traditional divisions at Westminster make it difficult to build the kind of consensus required to design a solution along those lines. But without such a consensus, the prospects for a solution – and an ageing society – are bleak.
South Korean women are neither especially diminutive nor remarkably lofty. With a mean height of 162.3cm, they are 12.5cm taller than their Filipina peers, and 7.5cm shorter than Latvian women. But they stand out from the crowd for one reason: they are a full 20cm taller than their ancestors a century ago. That collective growth spurt tells us something important: that height differences often ascribed to genetics owe a huge amount to nutrition, hygiene and healthcare. South Korea’s rapid development meant women’s growth was no longer hindered as it had been. In contrast, under-nourished Filipinas are still associated with “shortness”. Even within a community, cultural factors – such as an eldest son preference in South Asia – can lead to marked differences in height outcomes.
This is not a question of mere vanity. What really matters is not how tall one can grow, but whether one fails to grow as expected. More than 160 million of the world’s under-fives are stunted. In India 39% of children are stunted and in the Democratic Republic of the Congo 70%. Though stunting is a physical measure, and is associated with the increased risk of some chronic diseases such as diabetes in future, it is also an important indicator that mental development may have been affected. Their brains are unable to make the neural connections that they should; their cognitive ability does not blossom. Malnourished children also have little energy, further diminishing their ability to learn and escape poverty. Research suggests they are less likely to be enrolled in school, and learn less when they are there.
It is obvious why this bothers the World Health Organisation. But now the World Bank’s president is threatening to name and shame countries which fail to address the problem. Jim Yong Kim, a former doctor, says that stunting is not only the outcome of the unfair distribution of resources: it drives such imbalances, too, since inequality is “baked into the brains” of a quarter of children before they reach the age of five. The problem is not only humanitarian, but economic. And it is in the interest of governments to act – even if they are looking at the narrowest possible measures of national success – because they cannot compete if large portions of their workforces are stunted. Dr Kim’s ambitious goal is to halve stunting in seven years and end it in 14. A World Bank-sponsored programme in Peru, targeting families from pregnancy onwards, slashed stunting rates by giving conditional cash transfers to mothers, allowing them – and educating them – to give their children nutritious food and stimulate them through play. Health clinics were given incentives to support them. Swift action can bring immense benefits to a generation. Bodies and brains develop fastest in the womb and in the first two years after birth; it is hard for those who fall behind to catch up later. When we talk of children growing to their full potential, we speak more literally than we realise.
