Policy Pulse 08
Philanthropy, business support, a possible future for the NHS, and feeding the world.
Hello, and welcome to your selection box of public policy. This is the final Policy Pulse of the year, though it’s not a review of the last 12 months or anything like that, partly because this newsletter is still quite new, and partly because it probably wouldn’t be very jolly. But there are still interesting things to pick up from the last week, so let’s get started.
Report of the week: Minding the Giving Gap – Unleashing the Potential of UK Philanthropy by Pro Bono Economics
As it’s Christmas, I’ll tell you a story. I used to work for a fairly small organisation whose chairman at one time was very proud of having once met the President of the Coca Cola Corporation. He had observed to the President of the Coca Cola Corporation that he must face a great number of problems in his role, and wondered how he dealt with them. The President of the Coca Cola Corporation replied thus: “At the Coca Cola Corporation, we don’t have problems; we only have opportunities.”
In every board meeting therefore, whenever anything emerged that anyone described, or might be about to describe, as a problem, the chairman would recount what the President of the Coca Cola Corporation had told him. It became so well-rehearsed that for quite a long time after that chair had reached the end of his term of office and stepped down, whenever a problem was being discussed at a board meeting, someone was bound to ask: “Does anyone happen to know what the President of the Coca Cola Corporation might think about this?”
I was reminded of this by the Report of the Week. While it’s often a good idea to present things in positive terms rather than negative ones, to focus on the solution rather than the difficulty… sometimes it can seem a bit forced. In this report from Pro Bono Economics, the considerable drop in the value of charitable giving by the wealthiest donors (over a period in which their incomes have increased) is presented as an opportunity: if their philanthropy could be harnessed to the level it was previously at, the extra resources available to civil society would be considerable.
The changes over time are significant: charitable giving has become concentrated among fewer, wealthier households. With the donor base narrowing, a drop in the value of giving by the wealthiest group, among whom there is already a small “civic core” of donors, is bad news.
There are figures for the amount of funding that “could” be available for charities if this or that adjustment to giving patterns could be secured. The most interesting part is the third section, which explores why patterns of giving have changed and suggests possible fundraising approaches. Reasons are multiple and complex, but seem to include wealthy donors increasingly wanting more control of how “their” money is spent, and charities increasingly targeting known high value donors rather than seeking out new ones.
While this report points a way to possible solutions, it still reads to me as something that outlines a challenge and possible ways to overcome it. Much firmer analysis of the nature of the problem and clearer evidence that it can definitely be solved would be needed for it to convincingly appear like a genuine “opportunity” – to me, anyway.
Letter of the week
This week’s letter relates to the rapidly deteriorating COVID situation, in which the lack of economic support for businesses and individuals is becoming a major problem as consumers change their habits and some businesses are disrupted by COVID-related absences.
Even by last Wednesday – and it feels as though things have deteriorated a great deal even since then – live performances were seeing heavy enforced disruption, and growing numbers of voluntary cancellations, and the General Secretary of Equity wrote to the Chancellor of the Exchequer asking him to get across the problem. Of course, we know now that the Chancellor wasn’t in the country at the time.
The letter asks not only for the reinstatement of some previously available measures, but also for rectification of shortcomings in them that were never sorted out, with self-employed workers facing far too many barriers to support. As I write, there is no sign of any movement on this.
Question of the week
In another Christmas song-inspired question, I’ve been wondering: can we feed the world? With a growing global population and well-known environmental pressures, there are many aspects to this challenge. But I was particularly keen to get a better understanding of the role fossil fuels play in fertilising crops, and whether we can feed the world without them. The need to do so is twofold: we need to bring greenhouse gas emissions down; but also, fossil fuels are finite – a global population level sustained by a resource that is guaranteed to run out will inevitably become unviable at some point.
The short answer appears to be: yes, we should be able to do that, as on a technical level it looks doable. Whether we will succeed depends (as ever) on a large number of policy choices that could go either way. A slightly longer answer is that cutting fossil fuels out of the fertiliser supply chain won’t fully eliminate the considerable contribution of fertiliser to global warming. Whether we can feed the world while also achieving that aim appears to be a bit more heavily disputed.
So, first things first: where do fossil fuels fit in with fertiliser? This was taught as part of GCSE chemistry (when I did it, anyway), but awareness of it seems pretty low. Common fertilisers are nitrogen-based: that is, they contain ammonia, made up of hydrogen and nitrogen. In currently standard manufacturing processes, the hydrogen is obtained from fossil fuels (and the carbon released as a by-product is used to create carbon dioxide, hence recent gas price spikes causing a CO2 shortage, because fertiliser plants shut down). These synthetic fertilisers may be supporting up to half the world’s population.
However, consideration of this question quickly throws up the problem that while producing fertiliser without fossil fuels might make its long-term supply sustainable, it won’t end the environmental harms caused by these fertilisers. These arise not only from the production of the fertiliser (and with it, greenhouse gases), but also the use of the fertiliser in growing food: it works by microbes in the soil processing the fertiliser and producing nitrous oxide – a greenhouse gas much more potent than carbon dioxide. Use of these fertilisers has grown by 800% since the 1960s, and is projected to increase by 50% from its current levels in the next thirty years.
It might also be added that agriculture is polluting in other ways: not only are its greenhouse gas emissions enormous (greater than cars, trucks, trains, and aeroplanes combined, via fertiliser, cattle production, rice production and deforestation), but also a heavy user, and polluter, of water.
So, can we make nitrogen-based fertiliser without using fossil fuels? In principle, yes: we can get the hydrogen by electrolysing water. It’s an example of a process where hydrogen obtained via clean electricity might be better deployed than for fuel (as discussed when I looked at hydrogen) The Australian government is putting funding into making the process viable on an industrial scale, and quite possibly it could become economically competitive with traditional methods when its cost comes down. The other option being explored is carbon capture and storage, to avoid releasing the carbon dioxide into the atmosphere; but that would not end the reliance on the finite supply of fossil fuels, and the criticism of CCS technologies that they are still unproven at scale remains current, as far as I’m aware.
But even if we can do all that, should we? It doesn’t solve the problem of adding to greenhouse gases in the atmosphere. Surely the better solution is to use other methods to meet our future food needs? Unfortunately the picture here appears less clear-cut, and is bedevilled by wider debates between different schools of thought on agriculture. It might be one to revisit at more length as a question of a future week, but there are strong divisions of opinion between using both approaches, and switching fully to organic farming methods.
On the one hand, it’s argued that modern mechanisation, including computer-controlled precision application of fertiliser, can greatly reduce the amounts needed. On the other, proponents of organic methods argue that in practice no reduction in fertiliser use has actually been demonstrated at scale through these methods. They suggest that other methods to secure and improve soil fertility and consistently high crop yields are available, and that the challenge is to ensure farmers have the knowledge and wherewithal to use them to good effect for their own circumstances. But can these methods genuinely grow enough food for nine billion people?
There are big structural issues at play here. One is that we do not use the calories from all the food we grow efficiently. Only 55% of calories from crops are consumed by people: over a third goes to livestock, and another 9% or so is used for biofuels or other industrial products. Livestock is an inefficient way to get calories: for every 100 calories fed to a cow (industrially farmed beef being the worst offender here), only three calories are available from the meat it eventually yields. On top of that, food waste in the developed world is a well documented problem. Taking these factors together, there’s reason for optimism that we can indeed grow enough calories to feed the future population, but the barriers to actually doing it are very substantial.
Proponents of organic methods also point to 70+ years of global development based on nitrogen fertilisers: international actors including the World Bank and, of course, big business, encouraged a “green revolution” in which agriculture around the world switched to “semi-dwarf” crops (wheat, rice, maize) that depend on nitrogen-based fertilisers to produce their large yields. They argue for replacing these crops with others that suit local circumstances better and don’t need the large volumes of fertiliser, but also that large seed and fertiliser companies represent a vested interest that will resist this.
So yes, we probably can feed the world without fossil fuels. But it’s probably not quite the right question. Can we secure enough food for the long-term without stoking global warming might be the better question: and as so often, the answer might be yes… in principle.
Matters of note
Note: I make reference here to some of my day-job work, but the views I state here are mine alone.
An article in the New Statesman recently asked, “Is the Conservative government privatising the NHS by stealth?” Or rather, its headline did: the actual article spent quite a bit of its word count outlining the evidence for why accusations of NHS privatisation don’t stack up, and Anoosh Chakelian is far too sure-footed a writer on public services to fall into that trap.
However, the substance of the article does raise more serious concerns. When I last touched on NHS privatisation conspiracy theories, I linked to an older article in which I had written: “there are abundant Bad Things going on in respect of the NHS, and this is exactly the wrong time to be concentrating fire on a figment.” Anoosh’s article homes in on some of those bad things, and prompted me to revisit some concerns that I’ve had bubbling away at the back of my mind about where the NHS might end up, in, say fifteen years time.
The thrust of the NS article is that people are increasingly paying privately in order to by-pass NHS waiting lists. And of course this creates inequity in which people who can afford care get it, and those who can’t go without – for a long time, at least. Exactly the sort of situation that having an NHS is supposed to prevent. One might question why so much private healthcare capacity is apparently sitting around waiting for customers: earlier in the pandemic, the NHS had block contracts with the private sector to use their capacity, but these have now lapsed. However, you can expect efforts to address the backlog of planned surgery to make more use of the independent sector in the coming months, so that particular policy wrinkle might get ironed out quite soon.
But there’s more to this than just the short-term pressures of the pandemic causing waiting lists to rise. The under-funding of the NHS since 2010 has caused it to require people to fall back more and more on their own resources. There have been several initiatives to reduce the amount the NHS spends on certain procedures and medicines: these have been under banners such as “value based medicines” and “evidence based interventions”, and have offered positive rationales including reducing the use of older, less safe or less efficient treatments, or encouraging better decision making in which patients might choose fewer heavy-handed interventions. But the metrics given to support the aims of the exercises have always been framed in terms of cost savings to the NHS, not benefits to patients.
In a similar exercise, the NHS has also had a big push on requiring people to pay for their own over-the-counter medicines, and not offer them on prescription. Again, there is a superficial justification: it seems to make little sense for the NHS to pay pounds for what the individual can buy for pence. Although not all of these medications are low-cost painkillers and so on: they include things like headlice treatment, which can quickly get expensive if multiple uses are required in a family of several children. And while there are exceptions in the guidance and rules to allow GPs to use some judgement, in practice it is convoluted stuff that is bound to be applied wrongly a lot of the time: it’s by no means unknown for GPs simply to refuse to prescribe, even when the guidance says they should consider it.
There are other examples. Removing earwax has been deleted from the GP contract, so most patients will now have to pay privately. Again, there’s a fig leaf justification: GPs will advise patients to use olive oil and eardrops, which often clear blockages. But that’s what they always did anyway, and treatment to remove wax was only available for those patients who found the other approaches didn’t work. Now they have to pay privately if they want to get their hearing back, which can easily cost somewhere around £70 – how many people are walking around partially deaf today because they can’t afford it? Perhaps not many, but there will be some.
NHS Continuing Healthcare is a further battleground: this is the round-the-clock care provided in their own homes to people with high levels of need. The framework for assessing patients was always wonkily designed and inconsistently delivered, but things have deteriorated massively over the last half decade or so, with fewer and fewer people getting it, despite rising levels of need that should qualify people to receive it (indeed, it looks a lot like social care looked a decade or so ago).
These examples don’t even get into the high profile stuff like rationing of IVF cycles by hugely varying amounts between different local areas, or the NHS imposing spurious bars on things like knee replacement surgery – requiring people to lose weight or stop smoking first – in order to delay having to pay to provide the operation. Plus, of course, the scandal of NHS dentistry highlighted in the NS article, which has been a well known failure for years and years.
What happens to people who need these and other items of care but can’t get them? I’m not aware of comprehensive research on the question, but when I’ve looked into it, I’ve found what looks like that same pattern of people who can pay privately doing so, and people who can’t simply going without. Again, this is exactly what a National Health Service is supposed to avoid. Multiply it up across all the various areas in which NHS care has been pared back, and the number of people who have been on the receiving end of something like this must by now be quite large.
What might be the logical destination for all this? Well, it’s not privatisation of the NHS itself: as we’ve seen in social care, if a service is not given adequate public funding, it becomes unattractive to private companies, who either don’t enter the market at all, or end up handing their contracts back. Much more likely is that it would involve an overtly mixed model, in which it is transparently set out that the NHS will only do certain things, and beyond that you pay for yourself. The NHS might become a portal for your care, but not a funder of it beyond in a basic set of circumstances. Think of Anne Reid’s character in Russell T Davies’ acutely observed warning series Years and Years: she is offered a choice of an appallingly long wait to restore her sight, or the ability to pay the NHS to fast-track the operation, for £10,000. Something along those lines might be plausible, offered at scale and as part of the basic deal of the NHS, rather than covertly and haphazardly as is increasingly happening anyway.
But, you might object, the British people love the NHS. Blatantly undermining it as the universal provider of healthcare, free at the point of use, is electoral suicide for any political party. Indeed it is, and that explains why the drawing back of NHS services has been so partial and covert: it’s a result of under-funding and is very haphazard, not any sort of plan. However, while in opposition in the 2000s, the Conservatives were floating ideas like healthcare vouchers or allowing people to top-up their NHS care (still a strict no-no – you get what the NHS provides, or go privately, but you’re not allowed to add your own funds to the NHS’s provision, for instance to add an extra feature to your NHS wheelchair that the NHS won’t pay for). David Cameron kicked such ideas into touch when he became leader, recognising them as electoral hemlock. But this is the crucial point: suppose they prove not to be electoral hemlock in the future?
Predicting medium to long-term trends is a mug’s game. Back in 2001, who would have predicted the Brexit referendum result? Well, plenty of people might have guessed that a referendum would go like that if it took place, but few would have predicted it would actually be held. So, if we try to think the equally unthinkable about the NHS, what might we come up with? Or putting it another way, can we imagine a route to a situation in which fundamentally altering the NHS settlement as described above might be electorally acceptable?
I think the opportunity might just open up. On top of the growing problem of the NHS paring back its provision, add the shock of the pandemic. It has created a rupture between many patients and the NHS: their relationship with it is broken, and they increasingly feel the support they relied on it to provide is no longer available. I first wrote something to this effect over a year ago, drawing on results of a survey covering the period of the first lockdown: it seemed like a dramatic thing to say, but it was a detectable inference from the answers people were giving. Where are we now? In a situation with growing reports of aggression and violence against GPs and their staff, as people struggle in huge numbers to get appointments either in a timely way, face-to-face, or at all. Anecdotal reports are also flying around that more and more people are simply failing to get into the healthcare system at all: I would expect to see more solid research quantifying this emerging before long, and of course it’s a well established feature of the social care system. Some people are just giving up on the NHS; it doesn’t seem to be there for them any more. And for those people who can get care, they often find the experience of doing so a nightmare, with appointments poorly administered and inconveniently arranged, and poor communication about what’s going on. If that famous bit of the Olympics opening ceremony were to be broadcast on national television next summer, how would it land? Not so well, I suspect.
But what might that add up to in, say, a decade and a half from now? Well, consider that the Conservative Party will probably have a period in opposition during that time. Maybe by 2036 it will have got back into office, or maybe it will be making a serious tilt at it. Next time it is in opposition and develops ideas to the effect of changing the basic deal offered by the NHS – replacing it with healthcare vouchers, or leaving it as a basic settlement to be added to privately – will people feel so automatically switched off, and so affronted at the idea of the NHS being undermined? Or might enough of the electorate look back over the past couple of decades, conclude that actually the NHS isn’t all that, and vote to do things differently? There’s nothing inevitable about that, but I don’t think it’s any more fanciful that Brexit would have sounded in 2001.
The NHS will at some point be putting a lot of effort into “resetting the relationship” between itself and patients. It would do well to recognise that for many patients it needs not to reset the relationship but rebuild it entirely. If it does not, and instead attempts a “reset” that involves making clear to patients that they can expect less from the NHS in future, its leaders might be shocked at where that road ends up taking them. But in its fundamentally under-resourced state, the NHS’s leaders undoubtedly have a difficult task to steer a course to somewhere more positive.
Thanks for reading
So, on that cheery note, that concludes things for Policy Pulse in 2021. I’ll be back in either two or three weeks’ time, depending when new policy material that’s worth talking about starts to emerge in the new year.
In the meantime, thank you for reading and subscribing (if you have; and if not – get on it, it’s free!). It only remains for me to wish you as safe and as happy a Christmas as possible, and a peaceful new year. See you in 2022.