Letters: Perspectives on changes to the NHS

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Fragmentation would be disastrous

The Prime Minister has promised to make "all necessary changes" to the Health and Social Care Bill ("Minister; tell us your fears about NHS reforms – but we might not listen", 7 April). As a first step he has identified the rationale for change – an ageing population and increasingly complex treatment. Unfortunately, the legislation is worded so vaguely that it would allow healthcare to be fragmented, making it almost impossible to respond to these challenges. The evidence is apparent from the US, where death rates from common chronic disorders are many times higher than in the UK.

There are now four simple changes that the Government can make to provide some reassurance. First, restore the duty of the Health Secretary to secure or provide a comprehensive service and be the only person, subject to Parliament, who can impose extra charges for NHS treatment. Second, commissioning bodies must be public authorities responsible for a geographically defined population, ideally coterminous with local authorities.

Third, commissioning bodies must have a statutory responsibility to ensure that their decisions do not threaten the viability of existing NHS services, unless there has been an explicit decision to close them.

Fourth, Foundation Trusts must not act in any way that leads them to be considered "undertakings" under competition law.

There are many other aspects of the legislation that also need to be considered but for now we should know if the Government will incorporate these requirements in legislation, as has been called for by the Liberal Democrats, and if not, why not? Otherwise his "listening exercise" risks being interpreted as deceit.

Professor Martin McKee CBE, London School of Hygiene and Tropical Medicine, London N4

'Natural pause' is just a PR exercise

This "natural pause" is no more than a public-relations exercise and it is quite clear that Andrew Lansley plans to press on with the reforms despite the anodyne pronouncements to the contrary.

This approach is very similar to the local consultation that has recently been undertaken in the Mansfield area regarding the proposed relocation of the Ashfield walk-in centre to the Kings Mill Hospital accident and emergency department.

The local population were advised that a fully informed consultation was to be undertaken but it was clear from the outset that the decision to relocate the walk-in centre had been taken before the consultation had started and despite the considerable opposition to the move that was expressed by the public during the "listening exercise".

Dr Julian Law, Southwell, Nottinghamshire

AV costs wildly exaggerated

I share Nick Clegg's concern (report, 5 April) that NO2AV's figure of £250m as the cost of switching to AV appears to defy all reason.

AV will involve some extra counting and therefore extra expense. Starting with assumptions erring on the side of generous (half the population votes, counters paid minimum wage, six seconds to redistribute and re-count each reallocated ballot, ballots reallocated once on average), I still get a figure of well under 1p per person per year as the additional cost of AV.

Do NO2AV have any evidence to back up their claim? They don't seem to offer much on their website.

Eddy Hunt, Tonypandy, Mid Glamorgan

Peter Garside claims that whereas first-past-the-post voting might "seem" unfair, AV and PR are no better (Letters, 5 April). Yet he supports this by appealing to notions of fairness based only on first-choice preferences – expressed in crude, simplistic, FPTP terms.

Of course, it's often the case that there is no candidate whom the majority of voters consider the best – so whoever wins, most of the electorate will be disappointed, to some extent. So it seems reasonable to assume that the fairest voting system (if there is one) will be that which minimises voter disappointment.

All too often, FPTP delivers a winner whom the majority consider their least favourite (at least, among the major contenders).

AV and the various types of PR, on the other hand, tend to deliver winners whom most of the electorate find more or less acceptable. So the majority of voters are either delighted with the result, or at worst, moderately disappointed – less so, in most cases, than they would have been under FPTP.

Andrew Clifton, Edgware, Middlesex

A Bramley-Harker (letters, 4 April) is not correct in saying that AV will give anyone a second bite of the cherry. What it does allow is that we can all state that in the ideal world we would prefer candidate A but if that is not an option we would lend our support to candidate B.

We will all end up with one bite each, but it may not be the exact bite that we had hoped for. That is how politics works.

S U Sjolin, Bury St Edmunds, Suffolk

I am a bit perplexed by this post that the nay-sayers wish to be past. No one can show where it is until the race has been run. Whereas 50 per cent is not only recognisably an "a priori" post, it happens to be the point where a true majority starts.

Proportionality apart (a rather different issue), this is surely a no-brainer.

John Bone, London SW6

Student-fee plan is causing panic

In adopting the recommendations of the Browne Review, the Coalition anticipated an average fee around the middle of the £6-9,000 range, but this is not happening ("Cable desperate to stop fees stampede", 7 April). Now an air of panic is descending on Dr Cable's office. The Treasury risks having to guarantee a much higher loans budget; many graduates will find their debts unsustainable – or even unpayable – and others may simply emigrate, putting enormous cost on the Student Loans Company, the Treasury, and the Home Office in chasing debtors.

Other risks include a collapse in student numbers, closure of universities (with dramatic impact on local economies), and the entrenchment of graduate debt over many decades.

Some astute and particularly able students will choose to study abroad where fees are usually much lower and quality is at least comparable. A minority may make a lifestyle choice to work part-time or not at all and avoid paying back their loans by being low earners.

If a research student wanted to design chaos into a higher education system, he or she could merely describe what is happening to our universities.

Simon Sweeney, York Management School, University of York

You report that research by the Office of National Statistics finds that "on average graduates earned £12,000 a year more than non-graduates over the past decade (£30,000 rather than £18,000)".

I suspect that most graduates do not do jobs which specifically require a degree (engineering, medicine, teaching and so on) and so an extremely relevant question for potential graduates to ask (just before they take on their student debts) is "How much more does a graduate earn in a job which does not necessarily require a degree?" (sales, administration, general management, bookkeeping, advertising and so on).

If the salaries of those needing degrees is stripped out of the equation above, what is the difference? I run a company employing around 50 people and although some do need degrees (to teach, for example), others certainly do not and I have seen no evidence over many years that having a degree makes those people better employees, or gives them the potential to earn more.

David Wilkins, London W1

Cuts are no less than barbaric

If the Arts Council England's cuts last week were not barbaric in their own right, one sector has been especially heavily hit (report, 28 March).

The cuts to Writers in Prison Network and two other award-winning companies from 2012 means that the arts in the criminal-justice sector has lost three of its six ACE-funded organisations.

ACE will continue to work with us for the next year and to support our application to other (smaller) pots of funding but this in no way replaces what it has taken away.

Why should we care? Surely offenders, by the very nature of their anti-social behaviour, do not deserve the arts? Pause for thought. There are 85,000 people in prison today, and all but a handful are coming out on a street near you soon. Do you want them better or worse?

All these arts companies are dedicated to turning people's lives round in prison so that they don't reoffend. ACE has replaced these companies with... nothing. How does that contribute to the Lib-Dems policy of the rehabilitation revolution?

A writer's residency in prison costs £20,000 per year. The average cost of keeping someone in prison for a year is £47,000. If one of my writers turns round just one offender that's £47,000 a year saved for every year of their not reoffending.

The barbarians are at the gates. The Big Society just got much smaller, Mr Cameron.

Clive Hopwood, Director, Writers in Prison Network, Welshpool

Stephen King's "Economic Outlook" (4 April) did at least cast doubt on Osborne's pipedream that savage cuts in public spending will usher in a private-sector supply-side economic recovery.

Price Waterhouse Coopers estimate that every job lost in the public sector will mean another job lost in the private sector, so if 450,000 jobs in the public sector are lost, we could be looking at close on a million extra unemployed some three years hence. It could actually be worse than that with powerful downward multiplier effects kicking in.

King goes on to reject the Keynesian alternative, too, suggesting that whatever governments do, we're all doomed. He should be reminded that in 1945, with gross government debt four times larger than now, Labour and subsequent Conservative governments spent their way out of debt by maintaining high levels of employment, thus maximising tax receipts and minimising the bill for benefits. The National Health Service was created, living standards rapidly rose, and inequality was reduced. More of the same now would have the same effect, so why not just do it?

The alternative is to leave millions of ordinary people wishing to consume goods and services but without the income to do so, and millions of people willing to produce those goods and services but unable to do so because they are unemployed.

There is an overpowering logic in putting those people back to work. That cannot happen unless the government takes action to create jobs, raising spending in the most labour-intensive areas such as construction and the public services. Annual deficits and Britain's gross debt would then start to fall just as they did in the quarter century after 1945.

Kelvin Hopkins MP (Lab, Luton North), House of Commons, London SW1

Nostalgia for the BT of old

I often disagree with Dominic Lawson, but he had me virtually eating out of his hand in arguing that Labour is much more "ideology-driven" than the Conservatives ("'Ideological' is Labour's empty insult" 5 April) until he picked on British Telecom as an organisation "infinitely more responsive to the public once they were no longer part of the apparatus of the state".

Perhaps Lawson has never had to do anything so menial as to report a BT fault, but I can assure him that in the days of "the apparatus of the state" it was possible to dial a three-digit number and speak to a helpful local person who responded instantly. Now we have to listen to a machine which repeatedly informs us that it knows we are waiting and that our call is apparently important to it, before eventually connecting the (by now foam-flecked) "customer" to a call centre on the other side of the planet. We are then coldly informed that if the fault is found to be inside the premises then the "customer" will be charged £129; I can assure Lawson that this thuggish threat poses a frightening dilemma for the elderly, virtually all of whom stayed with BT, loyally thinking it would give the same old friendly and ideology-neutral service.

Maybe Lawson can suggest a better example: the monopolistic, overcharging train companies? Electricity? Gas? No, like the banks and supermarkets, the only ideology they know is sheer greed.

Aidan Harrison, Rothbury, Northumberland

Baffled by banking bailouts

We are told that successive governments are being forced to borrow massive amounts of money to finance the bailout of their banks which, unlike entire countries it seems, are too big to be allowed to fail. These governments are raising the money by the issuance of gilts which are sold to investors on the various money markets.

Can somebody assure me that the investors to whom we are selling debt obligations do not include the banks that the debt was created to save?

Des Senior, Ware, Hertfordshire

Tackle the tax dodgers

So David Cameron is telling Pakistan that it's "not fair" that some of its richest citizens pay no tax at all ("Cameron attacks Pakistan's weak governance", 6 April).

He is right about the injustice – but is he aware of how much Britain could be doing to help Pakistan and other poor countries collect the billions of which tax dodgers currently deprive them?

Britain and other rich countries could give Pakistan's tax authorities a huge boost by working internationally so that Pakistan has information about the wealth its rich citizens have hidden in overseas tax-havens such as Caribbean islands, Switzerland and so on.

Mr Cameron could also help Pakistan and other countries by pushing for changes in accounting rules for multinational companies, to require them to detail the profits they make and the taxes they pay in every country where they operate. This would make it much easier for tax officials to spot suspicious cases where multinational companies appear to be artificially shifting their profits offshore to pay less tax.

Christian Aid suggests that if he is going to lecture Pakistan about how to run its tax system, then Britain must do all it can to help the country catch up with tax dodgers.

David McNair, Senior Economic Justice Adviser, Christian Aid, London SE17

So we are to give £650m to aid Pakistani education (report, 5 April). Will this promote the teaching of evolution, the heliocentric solar system (rather than the geocentric solar system of the Koran) and religious tolerance? Or will it go towards Wahabi madrassas teaching a hatred of Jews and Christians?

Roger Ellis, Salisbury

Bob Marley's punk past

I was delighted to see your essay about Bob Marley (6 April), as I feel that his contribution to music is not acknowledged as much as it should be. He was, as you say, an inspiration to British punk bands in the late 1970s, but in some cases he was more than that; he wrote the song "Johnny Was" for Stiff Little Fingers, for instance.

I was, however, very disappointed to see you get the name of one of my favourite songs wrong – it was "Punky Reggae Party" not "Honkey Reggae Party". That mistake was not the best way to commemorate 30 years since Bob Marley died, especially as I cannot imagine him ever singing such lyrics.

Rachel Gallagher, Gravesend, Kent

Drug-war idiocy

Hope Humphreys (letter, 4 April) is right. The war on the "war on drugs" must go on! Drug prohibition causes much positive harm in terms of morbidity, mortality, criminal, social and economic mayhem. She is right that common sense and humanity should prevail.

We need properly conducted, independent research, of the sort acceptable to the UN, carried out in producer, transit and consumer countries, which clearly demonstrates the international, national and personal harm that prohibition causes. Perhaps then will there finally be the political will to bring about change that we crave.

In the meantime, let's keep writing to our MPs and your paper as Hope (now there's a name!) suggests.

Dr Nick Maurice, Marlborough, Wiltshire

History lessons

According to the grey-bearded Marx, history repeats itself, the first time as tragedy, the second as farce. Iraq was a total tragedy. Libya is an incontinent farce.

Zekria Ibrahimi, London, W12

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