Why we don't criticise the NHS

A recent survey showed that people are reluctant to criticise the care they receive by the NHS. Whilst we are happy to rate pretty much any service or good we obtain, from mobile phones to hotel stays, we are far less likely to say something critical about the NHS. The Guardian has reported on the result of this survey and the figures are revealing. Only about 250 people go online every day to rate their experience with the NHS, out of 1 million daily encounters in the NHS between care staff and patients.

The authors of the report suspect reverence for medical professionals the main reason. But another reason for why we rarely say much about the NHS is that we simply don't know. Look at it this way.

Rating a good or a service inevitably involves comparing it to a previous experience. We may often not be aware of this comparative exercise, but when we say something about a movie we have seen, we intuitively judge it against a previous movie experience. Although comparisons are complex mental exercises, the fundamental component of any comparison is a previous experience of something that we deemed sufficiently similar to compare it to. That may be easy with movies, yet harder to come by when we think about a colonoscopy. Experiences of medical care are mainly non-comparable, singular events in their nature. We do not have an operation to remove our appendix at Central Manchester Hospital and then decide to go to France to have the same procedure all over again. Once it's done, it's gone.

Not your usual NHS staff - or so you hope!

That illustrates of how little use NHS satisfaction surveys are. People simply have nothing to compare it with when it comes to medical care experiences. At best, they may re-visit the same hospital again and their rating may simply reflect whether or not the hospital itself has improved its care quality over time. Cross comparisons between hospitals or even between the NHS and other care organisations can hardly be based on patient satisfaction surveys.

As a foreigner, I have the privilege ( or perhaps the misfortune) to know two health systems, the NHS and the German system, a de-centralised health care model based on mixed economy health providers. I also work in a university hospital in Wales, one of the largest in the country. Although I bristle at the dire state of hygiene in NHS hospitals and the poor food, I could hardly comment on whether Welsh surgeons would do a better job at operating my appendix than any German doctor would. What I do know however is that if I hear any politician speak of how great the NHS is because they have the highest satisfaction ratings in years, I will roll my eyes and hope I never be asked to fill in one of those surveys.

Lisbon diary

Of all the cities in Europe I always wanted to visit Lisbon has long been top of the list. Perhaps it's the melancholy writing of Pessoa or the fascinating history of this country. Last year I visited Porto and fell in love with the language and the feel of the city: laid back yet organised, small yet big enough to have a fantastic concert hall and a beautiful city centre.

Now it was Lisbon's turn and I was not disappointed. In fact, I have rarely seen such a wonderful place for living and working. The city is big but not overwhelming, well run and clean. It has charm (and beautiful people needless to say), yet also retains a feeling of normalcy that makes it appealing and exciting at the same time.

The memorial dedicated to the discoverers in Blemel

Yet, the most fascinating aspect of Lisbon and Portugal may be its rich and exciting history. In particular, the last hundred years offer fascinating insights into the clash of modernity with pre-modern elements of life. If you look for manifestations of the recent past, you don't need to look further than Lisbon's trams. Although the city has a functioning and spacious metro system, it also kept its tram lines above ground which still prove a magnet for tourists.

Lisbon's tram

Perhaps the most intriguing detail of Portuguese history however is an aspect that is little discussed: the long 'freeze' under its last dictator, Salazar. The sheer length of his regime provides some staggering figures. Having come to power in 1929, he lived and ruled Portugal until his death in 1970. Although brutal at times, his rule distinguished itself from the previous regime, the last turbulent monarchic rule of Portugal followed by a brief interim republic, and laid the foundations for a semi-modern economy and society.

In a sense perhaps Salazar's dictatorship saw Portugal's slow transformation from a largely aristocratic regime into a modern republic, something that infuriated some because of its slowness and protracted nature, while being admired and envied by others who experienced radical social and economic transformations at the beginning of the 20th century leading to internal strife and civil war. Whatever the lessons of his long rule, Portugal is now fully integrated into the European Union and Lisbon is the Iberian pearl on the Atlantic.

What has the coalition achieved?

The coalition government under David Cameron has had a rough time recently. Surveys show that key ministers are deeply unpopular amongst the British people and the poll figures for both parties, the Conservatives and the LibDems, took a beating since the Rose Garden photo op in 2010.

Happier times! Cameron and Clegg in the Rose Garden of Number 10 in 2010

There have also been rumblings amongst Conservative members of parliament about the leadership qualities of David Cameron, prompted by a perceived advantage given to LibDems in key policy areas. Nick Clegg and his parliamentary colleagues, so the complaint goes, determine policies to a far greater extent than they should. Given the widespread disenchantment with the coalition one might be forgiven to ask: what is the point of the coalition? Has it achieved anything so far?

The most effective opponent of the coalition government is not Her Majesty's Opposition, yet perhaps time itself and the tendency of all electorates to indulge in selective memory. It is easily forgotten how radical this government actually has been, much to the consternation of some former Labour ministers who had similar plans for transformations of public services, yet either never got round to implement them or were blocked by Gordon Brown.

Just reviewing a list of recent reforms reveals the magnitude of the policy programme of the current government. Fundamental change and reforms have received legislative approval in education, health, constitutional affairs and welfare.

Take welfare for example. James Purnell was the one but last Labour Welfare Secretary and his plans for welfare reforms approximated closely those of the current postholder Ian Duncan Smith. When in power, Labour had a keen awareness that the current trajectory of welfare spending was unsustainable in the long term. Ian Duncan Smith, starting in 2010, implemented a radical shakeup of the welfare and benefits system which, for the first time in more than 30 years, involves the re-assessment of benefit recipients for payments.

Despite some criticism from disability rights organisations the reforms seem to be largely in tune with the views of the British public and there seems to be widespread consensus that benefit payments require better targeting at those in need. Ian Duncan Smith carefully built the case for reform and is about to implement it, ceaselessly reminding reform opponents that simply continuing to increase welfare expenditure is not an option and may exacerbate inbuilt injustices.

In other words, he managed to locate the current reforms in the wider context of equity and justice, as well as present them as largely continuous of previous postholder's intentions. Similar feats have been pulled off by the Education Secretary Michael Gove, who argued that his education reforms are in essence an extension of the academy programme started by Labour under Tony Blair.

Yet, how truly radical the policy agenda of this government has been is only revealed by looking at those areas that have little resonance with the British public. It is in matters such as constitutional affairs that investing political capital rarely pays off and hence little progress is often made over decades. Shortly after coming to office, the coalition legislated for fixed term parliaments which removed the prime ministerial prerogative to set the date of the general election, something not even Labour was ready to give up.

After only two years, the record of this coalition government compares positively with Tony Blair's first term, even though he always regretted not having adopted a more radical approach when coming to power. Yet as selective as collective memory might be, it is also usually arriving at a more balanced appreciation of achievements as time goes by. John Major's government, though deeply unpopular at the time, might be a case in hand. Major's term in office is now seen as laying the foundation for the unprecedented economic recovery in the second half of the 1990s creating the space for the expansion of public expenditure under Labour. In this sense, Cameron and Clegg may have their best time still ahead of them.

What's wrong with Wales?

The Welsh economy has been in decline for the last 4 years. Not only that Wales has been hit hard by the recession since 2008, it also seems to be caught in a vicious cycle. Since inward investment is difficult to come by, economic activity in general is low in Wales which makes it an unattractive place for any investor to be. On top of that, the economic policy of the Welsh Government does not help. The Labour government under Carwin Jones has mainly one objective: to keep the public sector as large as possible since it is public sector jobs that form the main electoral pool for his party, and because public sector employment is often the only mechanism to address structural unemployment in some areas with low economic activity.

The result of this devastating policy and the long term structural problems of the Welsh economy are reflected in the economic figures. In almost all indices of economic activity Wales lags behind all other regions, whilst it leads the four home nations in almost all statistics of government expenditure. Government spending in Wales as a share of GDP has been 57.4% in 2007/8. The comparable figure for London (with plenty of government activity!) was 37%. That's a 20 percentage point gap between the two areas.

But look more closely and the figures reveal an even more shocking picture. Wales also lags behind in terms of productivity. The gross added value in Wales compared to the whole of the UK (100) is 74, leaving Wales way behind any other region as one of the least productive of the UK.

How difficult it is to break out of this vicious cycle of enormous government expenditure and low economic activity has sparked a lively discussion amongst economists and policy makers. The only person who seems to show little interest in tackling the deep seated problems of Wales is the First Minister himself, Carwin Jones, who explained in a recent interview with the BBC that, I paraphrase, everything is just peachy and, once Wales will have internet broadband in 2015, she will pull ahead of the other home nations (at 43 mins into the interview).

The poor performance of Carwin Jones as a First Minister and his government is widely acknowledged amongst commentators and reveals one fact above all. They still have no strategy how to pull Wales out of this mess which they have permitted to develop over the last 12 years in power. There are plenty of possible solutions. None of them however appeal to Labour politicians since they would damage their long term electoral strategy in Wales. The most attractive way out of the situation would of course be to shrink the public sector and to free up governmental expenditure to invest in the upgrading of infrastructure in Wales. There can be no doubt that the current ratio of governmental spending stifles private investment and economic activity. The state in Wales has become the Leviathan that devours all else.

The other way to improve Wales' economic future would be to stop introducing petty legislation through the Welsh Assembly. Since the Labour dominated Welsh Assembly has been created it has either idled its way through the decade or engaged in matters, at best, peripheral to the state of the economy, at worst, detrimental to its growth prospects. Part of the explanation is that Welsh Assembly members of all parties are of fairly low calibre. Any politician with political talent tries to get a Welsh seat for the House of Commons rather than wasting their time in the Welsh Assembly. With a severely restricted talent tool for the Welsh Assembly, debates are often either painfully partisan and tribal, or focussed on politicians' pet projects such as the organ donor legislation or legislation to make it compulsory to install sprinkler systems in newly built houses. Needless to say that neither of those are of any consequence to the Welsh economy.

The main response of the Welsh Government so far has been to blame others for the state of Wales. Carwin Jones and his Labour ministers are habitually pointing the finger at Westminster when they are criticised for their poor performance. It is London, so their story goes, who should shoulder the blame. The statistics however belie this argument as a cheap attempt to avoid taking responsibility for their own actions. Wales receives much more from the treasury than it puts into the coffers of the chancellor. In 2006/7, according to official figures, £19.3 billion were raised in taxes and duties in Wales, whilst governmental spending reached £28.2 bn in the same year. Which makes Wales a net recipient of public money.

It seems that as long as the Welsh Government is in denial about its own responsibility for the devastating economic situation in Wales and as long as the Labour party clings to the mirage that public sector employment is the only way to tackle socio-economic deprivation, little will change in the land of Glyndwr.

Why the US elections are so dull

'Four more years' the audience chanted, and 'U.S.A.'. In a sense, these chants represent the essence of the national conventions of both political parties who are vying for votes in the upcoming presidential elections in the US. Anyone wondering what the real choice between Mitt Romney and Barack Obama is may be puzzled and confused: no policies were articulated by either of the candidates, no plans for future investment or reforms of the education, health, transport sector. In other words: nil, zero, nada on the policy front.

Obama's greatest asset in the re-election fight - his wife Michelle

Worse however was to come for anyone who sat through the speeches of the candidates' wives. No cringe-making remark was left out, no personal comment to low to be made by the most private defenders of their characters. And while Vice-President Biden roused the faithful in support of Obama, former President Clinton once again showed why he sailed to victory at his re-election bid in 1996. His rhetorical flourishes were polished and well delivered, taking a shine off Obama's delivery which often looked wooden and flat.

But why are national conventions of both parties so deadly boring? Despite the hype in the media, neither of the candidates offered any policies or plans for reform and so much of the media talk is about personalities and character. The main reason for this may lie in the constellation of American politics: a system of checks and balances that often delivers an impotent president and an over-potent Congress with budgetary powers. Legislative proposals are hard to get passed for a president (with or) without a party political majority in Congress, so there is little point in delineating a future policy agenda for any contender to the highest office.

This contrasts considerably with UK politics, where the prime minister commands a majority in the House of Commons. With party political discipline (and a bit of luck to have few mavericks around) his voting majority for legislation in the House is assured, so he can deliver the things he proposed to do during the electoral battle. In fact, there is a singular focus in the public mind and debate of the UK on whether prime ministers and governments have in fact delivered what they have promised in their (admittedly, often vague) manifestos.

This close link between electoral strategy and policy agenda post-election also allows moments where opposition parties can upset the governmental cart. Anyone remembers George Osborne's surprise announcement at the annual party conference to lift the tax threshold for inheritance tax to £250,000? The poll numbers of the Conservatives firmed up instantly.

Of course, much of what parties and prime ministerial candidates promise is never delivered, even in the UK. But the underlying tendency is clear: public debate mainly focuses on policies for legislation and reforms rather than personalities. Despite all the admiration I have for the US, Britain may just have the edge in this matter.

Anyone running 200m in less than 22 seconds?

Anyone out there with a time around 22 seconds for the 200m? Well, certainly not me! But that's the extraordinary time that Pistorius ran in the qualifications for the Paralympics. Remember the world record stands at 19.19 seconds by Usain Bolt. So this is how close paralympians are to able bodied athletes by now.

Yet Pistorius was in for a surprise as Alan Oliveira from Brazil caught up with him on the London track and zoomed past him with a time of 21.45 seconds. Watch it HERE. What an achievement!

Alan Oliveira after he beat Pistorius in London 2012