Sweet stuff ... and nonsense

It was nice to see Geraint Davies, the Labour MP for Swansea West, come out in favour of a tax on sugary drinks in this tweet today:

With obesity soaring, a 20% tax on sugary drinks would cut obesity by 180K and generate £250 million of revenue to subsidise healthy foods.

— Geraint Davies MP (@GeraintDaviesMP) June 10, 2014

The reaction was for a number of Plaid Cymru supporters to say that this was Plaid's policy, put forward in our conference in October 2013. But, as I noted at the time in a comment on this post, it was not Plaid that came up with the idea. The policy had been put forward by Sustain, on behalf of over 60 organizations, in January 2013 in a document entitled, A Children's Future Fund: How food duties could provide the money to protect children’s health and the world they grow up in, and Plaid seem to have lifted the policy from them.

People can download the document by clicking the image.

     

Of course there's nothing wrong with a political party lifting ideas from organizations like this ... although the details will need to be refined. In principle, I think it's a good policy for public health reasons, and therefore one that deserves to be implemented. Even though I'd like the kudos of Wales doing it first, it doesn't really matter whether it's enacted across the UK (or whatever's left of it) by a government at Westminster, or across Wales by a government at Cardiff Bay.

Nor do I really care exactly how the money raised by such a tax is used. Wales does have a shortage of doctors compared with other countries, so Plaid's proposal to hypothecate it to employ a thousand more doctors is fine; but using it to "subsidize healthy foods" might work too.

So let's try and put our tribalism to one side and see if we, Plaid Cymru and Labour, can make it work. The Assembly already has the power to do this as a levy (in the same way as for single-use bags) so we could easily get it through before May 2016 if we put our minds to it without waiting for the Wales Act; but there's no chance of it even being considered in Westminster before May 2015.

Ultimate gender equality in Wales

The Office of National Statistics has today published a compendium of comparable statistics for Wales, England, Scotland and the Six Counties. They are available from this page, and should provide hours of interesting reading.

I've only just begun to look through them, but one statistic that caught my attention was healthy life expectancy.

     

I had thought that women living longer than men was something that was true everywhere. So I was quite surprised to see that healthy life expectancy is in fact equal for men and women in Wales. Elsewhere, women can expect a healthy life several years longer than that of men. On average 2 years longer in England, 2.7 years longer in the Six Counties and 4.3 years longer in Scotland.

Any suggestions as to why?

Speak Welsh, be more physically active

I must admit to being very pleasantly surprised by the substantial increase in the percentage of adults in Wales who have taken up sport or other physical activity in the last few years. The increase of 34% between 2008 and 2012 is quite remarkable, particularly because of the contrast to what is happening in neighbouring countries.

     Fitness bug sees activity levels soar across Wales

As people might expect, I wanted to look at these figures more closely. The full report from Sport Wales is entitled The State of the Nation – although I'd have thought A Nation Fit for Purpose might be a little snappier – and the figures are available in spreadsheet form here.

It probably won't be much of a surprise that younger adults participate in sport more than older adults, males participate more than females, and those in richer households participate more than those in poorer households. It is one of the sad realities of life that richer people tend to be more active, tend to eat more healthy food, tend to be less prone to illness, and as a result tend to live longer than those who are poorer. This is the main reason why we, as a society, need to do much more to narrow the scandalous gap between rich and poor.

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However there were three other groups in which participation rates in sport showed a more unexpected difference.

First, those who identify themselves as Christians are much less involved in sport than those who have no religion or are agnostic. The sample size for other religions was probably too small to be reliable. I'd be interested in people's opinions on why this might be.

Second, those who are gay, lesbian or bisexual are much more involved in sport than those who are straight. I think this might be explained by fewer gay people tending to have children, and therefore having more money to spend on themselves and more time to get involved in sporting and leisure activities.

But the third group is people that speak Welsh, who for some reason are much more involved in sporting activity than those who don't speak Welsh. These are the percentages, with Welsh-speakers in bold:

No frequent activity ... 32.45% ... 42.83%

Once a week ... 12.08% ... 11.89%
Twice a week ... 9.83% ... 8.67%
Three or more times a week ... 45.63% ... 36.62%

Any participation in last four weeks ... 78.74% ... 67.58%

Sports club member ... 31.33% ... 25.50%

Volunteer in sport ... 15.09% ... 8.95%

In every single positive category there is a markedly greater percentage of Welsh-speakers than non-Welsh-speakers. I have spent the last few hours trying to figure out what would explain this. There doesn't seem to be any geographical basis for the difference.

There are studies (for example here) which show that Welsh-speakers are likely to be better educated, less likely to be unemployed and less likely to be in poor health ... factors which would clearly seem to be linked with earning some 8-10% more than non-Welsh-speakers. But this difference in earnings alone would not account for why Welsh-speakers are more involved in sport.

If we look at the tables in detail, the percentage of Welsh-speakers who participate in sporting activity three or more times a week (45.63%) is roughly equal to the participation of people in households with an income of £31,200 to £51,999 (46.99%), and the percentage of non-Welsh-speakers who participate in sporting activity three or more times a week (36.62%) is roughly equal to the participation of people in households with an income of £15,600 to £20,799 (36.37%) ... but Welsh-speakers obviously don't earn twice as much as non-Welsh-speakers.

This means that speaking Welsh, in and of itself, strongly correlates with being more physically active in a way that can't easily be explained by other factors.

As I said, I'm at a loss to figure out why this is so, and would welcome people's thoughts on the subject. But if you are someone who wants to be more physically active, it looks like one answer is to learn Welsh ... or perhaps it's the other way round: if you're struggling to learn Welsh, the key might be to become more physically active.

The proposed e-smoking ban

I've just read this article by Victoria Winckler on the Bevan Foundation blog about the Welsh Government's proposed ban on smoking e-cigarettes in public places.

     

I agree with what she says and think it's well worth taking five minutes to read.

The real battle is to help people quit smoking tobacco, and e-cigarettes are more likely to be part of the solution than part of the problem.

What the Western Mail refused to publish

In this post yesterday, I criticized Plaid Cymru for not publishing any detail about our proposal for a sugary drinks tax or levy. As it happens, this was not entirely our fault because we had produced an article that explained the proposal in much greater detail. We asked the Western Mail to publish it, but they refused to do so.

This is an important policy from a party that might well lead the next Welsh Government after 2016. It impacts on two policy fields which are of crucial importance to Wales.

The first is that we have an obesity crisis that is getting worse. Dr Nadim Haboubi, a consultant at Nevill Hall hospital in Abergavenny and chair of the National Obesity Forum for Wales has said:

[Wales' obesity problem is] huge, massive, worse than England, worse than anywhere in the UK and among the worst in the western world, I would argue. The worst is probably the USA but we're certainly not far behind.

It's a drastic epidemic and it's worsening. It's because of so many reasons, such as inequalities, social deprivation and unemployment.

BBC, 31 August 2012

The second factor is that we have an acute shortage of doctors in Wales. This is from an article in the Daily Post in June:

Call to act now over Wales' doctor shortage crisis

Wales has fewer doctors per head of population than Kazakhstan and Moldova and lies 22nd in a league table of 24 European countries for clinical staff, Plaid Cymru claimed.

Analysis of World Health Organization figures showed Wales had 24 physicians per 10,000 people compared to 38 in Kazakhstan and 36 in Moldova. Only Poland and Romania employed fewer doctors by comparison.

Plaid Cymru leader Leanne Wood said that the Welsh Government had to tackle urgently its doctor recruitment problems if district general hospitals were to function properly. A shortage of clinicians has been a major factor in decisions over where to site specialist services, and were a key consideration in the suggested move of intensive care for premature babies to the Wirral. Ms Wood said: “These figures highlight the long term failure by the Welsh Government to effectively plan for the recruitment of doctors.”

Ceredigion AM Elin Jones said Plaid Cymru propose financial incentives to encourage graduate doctors to stay and work in Wales; investment to encourage talented Welsh students to study medicine; and promotion of Wales as a place to live and work, with increased recruitment from other EU nations. She said: “It is essential that the Welsh Government takes action to increase the number of doctors recruited to Wales. Wales is currently in the EU relegation zone when it comes to the number of doctors.”

Dr Richard Lewis, British Medical Association secretary in Wales, said: “The inadequate number of doctors applies to general practitioner numbers as well as hospital doctors. It is little wonder some patients find difficulty in accessing appointments in general practice. The answer isn’t in asking more of the already stretched GP numbers, but in increasing the GP workforce to adequate levels.”

Daily Post, 5 June 2013

To which I would add that decisions like the one to downgrade Accident and Emergency services at Llanelli from a doctor-led service to a nurse-led service, as reported here, would not be necessary if we did not have a such a shortage of doctors.

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It amazes me that the Western Mail should refuse to publish details of a policy that would make a big difference in two areas which are of such major concern to the Welsh public. It speaks volumes about the paucity of serious news coverage in Wales. The editors and proprietors of Western Mail should, quite frankly, be ashamed of themselves. It is blatant political bias which, on this occasion, allowed Carwyn Jones to both blatantly misrepresent our policy and claim that we had been "entirely silent" about it. We weren't silent, we were gagged.

     

This is the article that we asked the Western Mail to publish, which is has now been put up on the Plaid Cymru website:

Leanne Wood on the sugary drinks levy

A Plaid Cymru government in 2016 would have tax powers if the recommendations of the Silk Commission’s first report are implemented.

The Silk Commission says that Welsh Government should be able to adopt new and innovative taxes, particularly those with policy ‘nudge’ implications, like our proposed sugary drinks tax.

We have long had ‘nudge’ taxes to reduce consumption of tobacco and alcohol products and our sugary drinks tax should also be considered a public health issue.

Across the former coalfields of the south, more than 60% of the population are overweight. Excess calories contribute to weight increase. Rising levels of type 2 diabetes suggests a further link with sugary products.

Although innovative in Wales, taxing sugary drinks is not unique. The majority of US states have some form of ‘soda excise tax’ while Finland and Hungary both tax these products. A new tax was introduced in France last year and the Republic of Ireland has been considering the idea for some time.

According to the British Soft Drinks Association, an average of 227 litres of soft drinks is consumed per person per year. 39% of these are ‘regular’ drinks compared with 61% which are low calorie or no added sugar products. However, products with no added sugar can still be high in sugar, and can often contain other ingredients which are not good for you in excess, such as caffeine or aspartame.

The BSDA distinguish between a range of products. These include carbonated drinks (such as cola drinks), dilutables (such as squash), fruit juice and smoothies, still and juice drinks, energy and sports drinks (with energy drinks in particular often having large quantities of both sugar and caffeine), as well as bottled water.

61% of carbonated drinks consumed are considered ‘regular’ sugary drinks alongside 24% of dilutables and 58% of still and juice drinks.

Final details for a sugary drinks tax would be ironed out in consultation and legislation, of course. Plaid Cymru would consider the inclusion of all drinks which include additional sugar, as well as those which are high in natural sugars such as fruit juices and smoothies.

The Party of Wales believes that fruit juices and smoothies cause no problems when drunk in moderation, and will consider whether a full or reduced level of tax should be levied.

Our proposals are for a 20p per litre tax on sugary drinks (broadly 7p on a 330ml can, or 10p on a 500ml bottle).

We propose a tax on volume rather than price for two reasons. A tax on price would allow supermarkets to absorb the increase into the standard cost or discount bulk purchases, removing its impact. A tax on volume ensures consistency of pricing structure. Plaid Cymru considered whether a tax per gram of sugar should be implemented and concluded that this approach will be too complicated to introduce in the short term but should be re-considered at a later date.

Wales drinks approximately 306 million litres of sugared drinks, with a further 58 million litres of fruit juice and smoothies. At the full 20p tax rate on these, the take would be around £72.8 million or £61.2 million not including fruit juice and smoothies.

The overall aim is for public health rather than to raise tax revenues. In France, where the tax rate of 7c per litre was introduced, there was an immediate 3.3% sales drop. Using a higher tax rate, closer to that we suggest, academics estimate an elasticity of demand of around 8-10% for soft drinks.

Assuming a full 10% fall in sugared drink consumption, the tax take would be around £65.5m or £55m without fruit juices and smoothies.

The public health effect due to reduced consumption, based on models in the similarly sized Republic of Ireland, would be to reduce obesity by 10,000 people. In total, 15,000 people would no longer be overweight – with all of the related healthcare complications that being obese or overweight create.

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Plaid Cymru is committed to the introduction of 1,000 additional doctors to Wales. Currently, Wales has fewer doctors per head than almost every other country in the European Union and fewer than any other country in the UK.

Wales requires a range of doctors – with different grades and specialisms. Taking the median mid-point pay scale for various types of doctors would give an average wage for a consultant of around £82,000 p.a., general practitioners £70,000 p.a., associate specialists £62,000 and junior doctors around £33,000. There are further on-costs relating to employers’ NI and pension contributions in particular.

Assuming a mix, for example, of 100 consultants, 300 GPs, 200 associate specialists and 400 junior doctors and allowing for 20% for additional on-costs this would be around £66m.

Of course, this would not have to be funded from a hypothecated health tax. Incremental increases in doctor numbers could also be met by providing for an increase in the budget each year. An extra £13m per year over 5 years within the budget for a health priority should not be a problem. Savings from the £50m per year spent on agency and locum staff should also be possible if we have better staffing numbers and availability.

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These are bold, innovative and ambitious Plaid Cymru policies. The Welsh Government says that we can’t do it. We say that we can.

That ‘can do’ attitude and ambition to improve Wales is why Plaid Cymru must be the next Welsh Government.

The Slate, 14 November 2013

Allowing Labour to punch us in the face

Here is the exchange between Leanne Wood and Carwyn Jones from yesterday's questions to the First Minister:

     

When we announced the plan for a tax or levy on sugary drinks as a means to both reduce the consumption of sugary drinks and employ a thousand additional doctors in Wales, the first thing I did was was check to see whether the figures added up. It didn't take more than a couple of hours for me to see that they did, and I wrote this post about it.

The main point I made was that any policy announcements we make need to be backed up with enough detail to show that our proposals are practical and properly costed. But, despite my plea, we did not do this ... and the direct result of our failure to provide this detail has been to allow our political opponents to land the sort of punches on us that Carwyn did yesterday.

Carwyn is wrong. The purpose of the tax or levy (it will be a tax if we are allowed to introduce new taxes under the proposed Wales Act, but if the Assembly is not given these powers it can be introduced under existing powers as a levy) is to reduce the consumption of sugar as a public health measure designed to combat the very high level of obesity in Wales. Yet even after allowing for this reduced consumption, the money raised will fund a thousand additional doctors. It is a win-win proposal.

But I'm sorry to have to say that Carwyn had a point when he said that we have been silent on the issue and called the proposal a cheap and uncosted political slogan. Unless we publish the detail to back it up, that is all it is.

Will a sugary drink levy pay for 1,000 doctors?

One thing that I welcome about Plaid Cymru's approach to this year's conference has been an increased emphasis on policy. However I'm not sure we have quite worked out how to present it.

A perfect example of this is the announcement of a 20p/litre sugary drinks levy to fund 1,000 doctors.

It's a very clever idea, and on the face of it the sums appear to add up; but what is lacking is an actual set of figures to show how they add up. It isn't sufficient for Adam Price to say, as he does here, that the levy will raise between £50m and £60m.

What is needed is a simple, one-page calculation showing what is to be taxed, how much is consumed, and how much will be raised ... balanced against the cost of employing more doctors. This should be sent out in a press release on the day of the policy announcement, and downloadable from the Plaid website.

Hopefully this oversight will be corrected first thing Monday morning.

     

I can do some of the calculations here. The British Soft Drinks Association report for 2011 is here. On average, each person in the UK consumes 235 litres of soft drinks a year.

The question is how much of this can be described as sugary. Their breakdown is that 62% are "low calorie" or "no added sugar". But it should be noted that drinks such as pure fruit juices are naturally sugary, and that consumption of too much of what we tend to think of as "healthy drinks" also poses health risks in the form of obesity and diabetes. There are reports about it here and here.

Therefore I think it is reasonable to take the 38% of "regular" sugary drinks (89.3 litres per person per year) but add to it the figure for fruit juices and smoothies (19.0 litres per person per year) to give a minimum sugary drink consumption of 108.3 litres per person per year, or 330m litres total for Wales. At 20p a litre, this would raise £66m a year. The actual figure may well be higher than this, because we consume 23.4 litres per person per year of nectars and juice drinks, and a proportion of these will be naturally sugary.

In other words, it looks as if Adam Price was underestimating rather than overestimating the money that would be raised. I think it's safe to say that the policy would raise over £70m, based on current levels of consumption. My guess is that Adam was taking reduced consumption into account.

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The second part of the question is how much it costs to employ a doctor. There's a brief report on doctor's salaries here. More specifically, the Welsh figures are here. Without doing an exact breakdown, it would appear that an "average salary" is less than £40,000.

Of course there are additional employment costs in addition to salary, such as employer's NI and pensions contributions. It might well be that the figure of £83,000 quoted here is right, but it seems high and would therefore appear to cover other fixed costs which are probably already being paid for, even though the positions are vacant.

We should also remember that some of the current shortages in permanent doctors are being made up by expensive temporary and agency staff, and that there are significant costs in cancelling or postponing treatment because of lack of available staff. Both these costs would be saved, and these savings would therefore be added to the amount raised by the levy to fund the additional doctors.

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All in all, the figures stack up according to the rough calculations I have just done. All that is necessary now is for Plaid to officially publish a similar document. Quickly.

Carwyn: bogus, inept ... or worse?

One very odd thing about today's Welsh Government reshuffle is the health portfolio.

Only last week, Carwyn Jones announced that he was going to take the controversial Betsi Cadwaladr UHB reorganization decision personally. The reason he gave was that the proposed changes affected Lesley Griffiths' own constituency, resulting in a conflict of interest. These are his actual words:

"Just to make it clear, I will be taking that decision, because the minister herself has a constituency within the Betsi Cadwaladr Board area."

Wales Online, 15 March 2013

Even if that reason held water before, it certainly doesn't now. So what will happen? As there is no longer any conflict of interest, will Carwyn now hand the decision back to the new health minister Mark Drakeford?

•  If he doesn't, it means that the reason he gave last week was completely bogus.

•  But if he does, it means that last week's announcement was completely unnecessary. Or, to be more precise, means it was unnecessary if he knew that he was going to reshuffle his cabinet now. It would show him to be inept.

Neither of these reflects particularly well on his leadership.

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But there is another factor at play. At a guess, I would say that Carwyn actually intended to make the reshuffle not now, but after the matter of the health reorganization had been decided in a few weeks' or months' time. It would have allowed the new health minister to start the job with a clean slate.

The only explanation that makes sense to me is that Lesley Griffiths was not at all happy that Carwyn had chosen to take these decisions away from her. Presiding over health reorganization—or to put it more bluntly, health cuts—is an unenviable and thankless task, and the very least she could have expected was that she would be able to make the final decisions by herself.

I think Carwyn disagreed with the decisions she was about to make and therefore took it out of her hands, leaving her with no choice but to resign. That forced him into making the reshuffle sooner than he had wanted to.

After nearly 20 years, it's time to get serious

I normally wouldn't comment on an organization's response to a formal consultation without reading the whole thing. But because the British Medical Association have gone to the media with the aim of publicizing the key points of their position on the Welsh Government's proposal to improve Welsh-language services in health, social services and social care, I feel justified in commenting on what they've said.

The BMA’s response to the consultation said: “While Welsh-language service provision for some patients is essential, and does need to be recognised and effectively supported, it should not be a one-size-fits-all policy. If the aim is to improve patients’ experience of care, government efforts and investment would be better placed in tackling waiting times and filling staffing vacancies with the best professionals to deliver the best care.

“Today, the NHS is at breaking point; everyday we hear the same warnings. Imposing duties to offer NHS services in Welsh in a sector which in some areas is struggling to offer any service at all to its population is quite another.

“The time, and financial situation, is not right for imposing language duties on NHS organisations aiming to deliver world-class healthcare, but which in reality are many light-years away from that.”

Western Mail, 14 May 2012

The first paragraph contains a typical straw man argument. Nobody is suggesting that there should be a "one-size-fits-all policy" in respect of the Welsh language. But if the BMA is in fact acknowledging that a Welsh-language service is, to use their own word, "essential" for some patients, then we should welcome their acceptance of that. It's a start.

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Next, the BMA uses the argument that because the NHS is struggling, efforts to improve the service would be better directed elsewhere. The implication is that the standard of medical care is more important that the language in which it is delivered. My response is to point to the English NHS to see whether they accept that argument. Only a few months ago the UK government introduced new language rules on doctors working in the English NHS:

     Foreign doctors must prove they can speak good English

In essence, the GMC has been given explicit new powers to be able to take action against doctors when there are concerns about their ability to speak English, and at a local level "responsible officers" are to be appointed to ensure that doctors have adequate language skills. In practical terms, this means that even the very best doctors in the world will not be allowed to treat patients in England unless they have adequate language skills. It blows out of the water the BMA's silly suggestion that the "best professionals" should be appointed irrespective of their language skills.

Why should we accept lower standards in Wales? The same mechanism set up for assessing an employee or prospective employee's skills in English is just as appropriate for assessing an employee's skills in Welsh as well, so no additional administrative or cost burden would be imposed. Neither does it cost any more to employ someone who speaks both Welsh and English rather than just English. Nobody is advocating that every medical or care professional in Wales should speak both English and Welsh, but registering their language proficiency is an important step towards ensuring that sufficient Welsh-speaking health and care workers are employed and, more importantly, readily available to provide a service appropriate to the level of demand. This might well mean that Ysbyty Gwynedd in Bangor will need 70% of its front line staff to be able to speak Welsh, but that Nevill Hall Hospital in Monmouthshire would only need 10% of its front line staff to be able to.

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Lastly, the BMA claims that "the time and financial situation is not right" to impose any language requirements on the NHS. My response to that is much more dismissive. The Welsh Language Act of 1993 imposed a duty on all public bodies to treat Welsh and English on the basis of equality. Almost two decades have now passed, including times of economic boom and an unprecedented amount of money being poured into all public services, but especially the NHS.

But how did the NHS in respond to its obligations under that Act? There are some honourable exceptions, but in the main the NHS in Wales did not take them seriously. Getting a service in Welsh, either in health or social care, is generally more a matter of luck than of planning or forethought by the organizations that should have been providing it.
 

     

As it happens, today marks the start of a non-statutory public consultation by the Welsh Language Commissioner about the new language standards which will be applied under the new Welsh Language Measure. The consultation documents are here but, as we can see in this news item, the media focus seems to be on the private bodies that have now come under the scope of the Measure.

     

For me, a more important aspect of the new Commissioner's role will be to get public bodies which largely ignored their obligations under the old Act to now start doing what they should have been working on for the last twenty years. The old Welsh Language Board did not have any way of enforcing the old Act, it could do little more than name and shame those bodies which failed to do what they agreed they would; but the new Commissioner now has powers to set standards and some powers to enforce them.

The standards haven't yet been finalized and there is no way of knowing to what extent the Commissioner will have the appetite to enforce those standards when they are—and of course the BMA were responding to a similar consultation exercise by the Welsh Government, which has a different and more direct responsibility for the standards of health and care services in Wales—but my advice to Meri Huws would be not to go gunning for the bodies newly brought under the scope of the Measure.

To start with, it will be better to use enforcement powers on those public bodies which should have been doing much more than they have over the last twenty years ... and the providers of health and social care services should be right at the top of that list.

Darren Millar admitted to hospital

It's that time of year again. Listening out for first cuckoo of spring has been replaced by listening out for the first Tory to complain about free prescriptions in Wales. My reaction to last week's story was fairly similar to that of John Dixon in this post, where he wondered whether repeating the same old thing time and time again was actually more of a campaign than a simple act of reporting news.

I was, however, very impressed by some of the comments that followed the Western Mail's story, for they showed that people were no longer being taken in by unbalanced sensationalism being passed off as journalism. I didn't bother writing anything because I'd said almost the same thing in previous posts like this one, but today we have a follow up story in which the Western Mail concentrates on paracetamol. It is so bad that it deserves to be torn to pieces.

     Paracetamol prescriptions costing Welsh NHS up to £50m a year

     

In the first instance, the story is portrayed as an "investigation" and talks of "figures obtained by the Western Mail". Talk about an inflated sense of self-importance. No investigation was required, the information on the cost of all prescription items is routinely released every year. The Welsh figures were published on 28 March, and are available from this page:

     Prescriptions Dispensed in the Community, 2011

Paracetamol is in the "Chemicals P-Z" spreadsheet. The figures quoted by the Western Mail are correct, although one figure that they didn't publish would have been helpful. The total number of paracetamol tablets prescribed was 121 million, meaning that each prescription was for an average of 105 tablets. At a cost per prescription of £2.62, this works out at 2.5p per tablet or 40p for a packet of 16. Hardly an inflated price. This is what they cost at Boots.

But the idea that this can be inflated to "up to £50m a year" when the cost of consultation and dispensing time is taken into account is bogus maths of the highest order. People go to doctors because they are ill, want to know what's wrong with them, and want treatment for it. What you think might be just a persistent headache could be a brain tumour, and the real cost of a doctor's time will be taken up trying to determine whether it is just something minor or something more serious. Costs cannot be inflated in this way. The cost is what it is: just over £3m a year.

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Next we get the Tory spin. Darren Millar hints that if prescriptions weren't free for everyone the Welsh NHS would be able to spend this £3m on something else:

"It is scandalous that millionaires and other top earners can get paracetamol at the taxpayer’s expense.

"£3m a year would practically fully fund a Cancer Drugs Fund to enable cancer patients to access life-extending treatments currently denied on cost grounds. Labour’s universal free prescriptions policy is simply not sustainable."

This of course is the sort of misinformation we've come to expect from Tories (and on the specific subject of drugs for cancer treatment, see this comment). They imply that if it wasn't for free prescriptions, the Welsh NHS would not be spending anything at all on prescriptions for minor items like paracetamol and would therefore have £3m more to spend on other things. The truth is of course very different, as we can see by looking at the figures for a certain neighbouring country that still charges many of its people for their prescriptions.

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The English figures for 2011 were released on 4 April and are available from this page:

     Prescription Cost Analysis, 2011

The equivalent (though slightly less detailed) figures for England are that 20,879,114 prescriptions for paracetamol were issued at a cost of £2.93 per prescription. Although we don't know how many tablets were included in each prescription the cost per prescription is roughly the same, which indicates that things are essentially similar in both Wales and England. About 18 times as many prescriptions for paracetamol are issued in England, but England has a population which is 17 times larger than Wales. The conclusion is obvious, the prescribing pattern for paracetamol in Wales is almost exactly the same as the pattern in England.

However in cost terms, England spends £61,270,062 compared with Wales' £3,024,300 ... so England spends more than 20 times as much on prescriptions for paracetamol tablets, even though its population is only 17 times as large as ours.

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The Welsh NHS seems to have got it right. Which is just as well, for it means that there will be enough money available for the Accident and Emergency department at Ysbyty Glan Clwyd to treat an unfortunate Tory who happens to need treatment for a self-inflicted gunshot wound to his foot.
 

 
Update - 01:45 11 April 2012

Just in case anyone thought Darren hadn't really shot himself in the foot, someone has been kind enough to provide the photographic evidence:

     

The police apparently couldn't persuade him to hand over the gun, so he'll probably end up doing it again. But at least he can smile about it ;-)

Follow the Tories on the NHS ... just this once

It's not often that I agree with either the Tories or the Daily Mail, especially on anything to do with the Health Service; but this is one of the rare occasions where I do want the NHS in Wales to follow the lead they are setting.

As reported by the BBC yesterday, Andrew Lansley:

told the Conservative Party conference that GPs would be vetted to ensure they had adequate language skills and could communicate properly

and said that

proficient language skills were equally as important as proper medical qualifications when it came to doctors being able to practise in England

BBC, 4 October 2011

If this is something that goes ahead in England, there can and should be nothing to stop us doing something similar in Wales. The 1993 Welsh Language Act set out a duty for all public bodies to treat both English and Welsh on the basis of equality. But even after eighteen years, the chances of being able to get medical treatment in Welsh are patchy. This must change.

Up until now, the usual attitude has been that it was more important just to get medical treatment, and that the language it was delivered in was a secondary consideration. If people were able to get a service in Welsh it was regarded as "icing on the cake" rather than a fundamental part of the service offered.

So I welcome this long overdue change of attitude in England. I agree wholeheartedly that "proficient language skills are equally as important as proper medical qualifications" and would like to see the Welsh Government apply the same principle to the Welsh NHS as the UK government is about to apply to the English NHS.

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Obviously this doesn't mean that every doctor in Wales has to be able to speak both Welsh and English, but it does mean that Health Boards in Wales should have a statutory duty to ensure that sufficient Welsh speaking medical staff are employed and available to meet the demand for services in Welsh. This of course will vary from area to area, and vary over time as the number of people who speak Welsh increases.

As yet, the new Welsh Language Standards that will come into force as a result of the Welsh Language Measure 2011 have not been set, and it will be for ministers in the Welsh Government to set them. But the general principle behind the standards is that they should have positive effects on opportunities for people to use the Welsh language. Therefore it seems entirely appropriate that the relevant standards for Health Boards should include provision to both monitor language proficiency and increase the numbers of medical staff who are able to deliver medical care in Welsh so that everyone who wants a service in Welsh can be sure of getting it.

Bowel Cancer

This morning's Western Mail carries a story in which they claim that:

Wales is lagging behind England in tackling bowel cancer

But the figures they use show that exactly the opposite is true. Wales has 5,000 cases of bowel cancer per 100,000, of which 18 die ... a death rate of 0.36%. England has 4,600 cases per 100,000, of which 17 die ... a death rate of 0.37%.

Why the incidence of bowel cancer is greater in Wales than in England is a separate question; but the figures show that Wales is actually more successful in treating those who have the disease than England is.

The Tories need a dose of reality

Once again the news that the number of prescriptions issued in Wales has gone up has been met with the same old response from the Tories: "It's because they're free, and we should start charging for them again."

So once again I have to write a post explaining that the rise has absolutely nothing to do with how much they cost. Year on year, the number of prescriptions issued in both Wales and England goes up by about 5%. The 61.9% rise in Wales over the past decade is actually less than the rise in England, which has seen a 67.9% increase over the same period even though their prescription charge has kept on rising.

In fact the only thing remarkable about last year's 3.3% increase in Wales is that it is so low. As we can see from the link, the rise in England last year was 4.6%.

     

Yes, the number of prescription items per head is higher than it is in England; but it has been higher for many years, largely as a legacy in the form of chronic industrial diseases. The gap hasn't suddenly appeared as a result of free prescriptions.

The only explanation for this knee-jerk response must be that the Tories are suffering from the same sort of disease: a chronic inability to put statistics into perspective. But sadly it's contagious, because we'd expect a healthy news media to have picked up on this by now and do some analytic reporting, rather than just collating quotes and figures. For if the BBC has got it bad, the Western Mail's version is much worse. For them, the number of prescriptions has not just risen, the figures are now "massive" and "staggering". So perhaps a strong dose of sedatives is required too.

England's NHS IT system is at death's door

After nine years of trying and failing, the Public Accounts Committee of the Commons has at last come to the point of admitting that the flagship policy to produce an electronic records system for the English NHS is unworkable.

Pull plug on NHS e-records – MPs

The Public Accounts Committee said mounting problems with the electronic records system were making the £7bn project "unworkable". The group said the scheme – aimed at reducing the use of paper files – was beset by delays and uncertainty. If it was stopped, the remaining budget could then be spent on a better system, they said.

E-records are part of the overall £11.4bn IT programme. The scheme was launched in 2002 with the aim of revolutionising the way the health service uses technology. It includes developments such as digital X-rays and fast internet connections.

Under the e-records scheme, every patient was to get an electronic file that could be used when they were treated in the NHS. The MPs said it was a "worthwhile aim, but one that has proved beyond the capacity" of government to deliver.

BBC, 3 August 2011

It's sad, because if the project had been approached differently it could have not only have been successful, but done at a much, much lower cost. For an example of how to do it better, they need only look to Wales.

     

A year or so back, when another of the UK Government's computerization projects (the LIBRA system for Courts) was floundering, I came across this article by Michael Cross in the Guardian:

A Welsh cure for a nation's ills

Obama should look across the Atlantic for the huge task of computerising the US health records – but not as far as England

... For a lesson in how to manage the programme, Obama might do well to look across the Atlantic. Not to the NHS in England, where a £13bn programme is this year reeling from its latest parliamentary battering, but to Wales.

Earlier this month, Edwina Hart, the Welsh assembly's health minister, approved a plan to extend a system called the Individual Health Record (IHR) across the country. The decision comes seven years after the equivalent announcement in England, but no one need apologise for the delay. The Welsh IT team says that, by eschewing political deadlines and working with the NHS rather than trying to impose technology, it has created an electronic medical record that is not only more useful than its English equivalent but will cost a fraction of the price.

The secret, says Gwyn Thomas, chief executive of the agency Informing Healthcare, is to listen to users.

The contrast with the gung-ho English programme, now enervated by contractual rows and political grandstanding, is graphic. In the latest report, the chairman of the Commons public accounts committee, Edward Leigh MP, said: "Essential systems are late, or, when deployed, do not meet expectations of clinical staff; estimates of local costs are still unreliable; and many NHS staff remain unenthusiastic."

Wales and England started off with the same goal – to make computerised medical records available where they are needed. However, the two countries went about it in wildly different ways.

In England, the NHS took it for granted that the right technology was available and that staff were enthusiastic about adopting it. The central challenge was seen to be procuring the technology on the best terms, and implementing it to timetable. This involved a series of billion-pound contracts to provide central services and to rip and replace hospital systems across five regions created solely for the IT programme. Tellingly, one of the programme's explicit aims was to double the proportion of the NHS budget spent on IT. In Wales, by contrast, there were no big procurements and virtually no new money. When Thomas took up his role in 2005, he decided to work with existing technology to make information available where doctors needed it. Everything would move incrementally, with the consent of all concerned.

This involved several radical departures. In England, a central "spine" is designed to carry a summary record of every patient. The Welsh IHR draws data directly from GP records, with sensitive data such as terminations removed. Patients are asked for consent every time their record is viewed – unlike in England, which initially assumed patients to have given consent unless they explicitly opted out.

The Guardian, 29 January 2009

Now I certainly don't want to give the impression that the Welsh system has been trouble free. It hasn't. Mistakes have been made, companies providing services have gone bust. But because the Welsh approach has been fundamenatally different from that of the UK government in Westminster, these difficulties did not derail the whole programme. For those who are interested, there is a series of progress reports here:

     Health Insider, 8 January 2009
     Health Insider, 21 January 2010
     The Guardian, 19 October 2010
     Health Insider, 20 December 2010

To me, as a "health outsider", the picture seems to be one of steady progress; each step being taken after consultation and with consent, and with feedback informing the next step. Though I'd welcome any comments from people who know the system better than I do.

     

The IT records programme for the English NHS was described by one MP as "one of the worst scandals in terms of wasting public money", and another said, "Trying to create a one-size-fits-all system in the NHS was a massive risk and has proven to be unworkable."

It's timely illustration of the central conclusion of the research done by Adam Price and Ben Levinger as published in the Flotilla Effect. A reminder that being part of a large, over-centralized country brings inherent problems, and that smaller countries can more easily adapt to technological change by virtue of being smaller and more socially cohesive. We can tailor solutions to fit our own needs, rather than accept a one-size-fits-all solution from others.

Of course being able to make decisions for ourselves is no guarantee that we will make the right decisions. But if we compare our decisions about electronic NHS records in Wales with the unmitigated disaster of the decisions made by the UK government on behalf of England, it should give us all the confidence we need to press for more decision making responsibility in more areas to be transferred to Wales.

The Nuclear Legacy

Today is the 25th anniversary of the Chernobyl nuclear disaster, and harrowing though it is, it is worth looking again at the Independent's photo essay on the aftermath from last year. These are a just a few of the shots from it:

     

     

     

     

I certainly don't want to be sensationalist, nor do I want to overstate the dangers of nuclear power. My position has always been that the risks are low, provided that we spend very large sums of money on strict safety regimes.

Nevertheless, even with a such safety regimes, the risk can never be zero. We have to consider not just the level of risk of an accident, but the seriousness of the consequences if one happens. For example, if I walk on top of a two foot high wall around a flower bed in the local park on a clear, calm day, it's very unlikely that I'll fall off, and the worst that could happen if I did is that I would sprain an ankle. If I walk on top of an equally wide parapet wall at the top of a ten story building overlooking that park, the risk of me falling is exactly the same, but the consequences of falling are very much more serious. I might do the first, only a fool would do the second.

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As Wales can easily produce all the energy we need from renewable sources, it is foolish for us to spend huge sums of money on nuclear, not least because we will have to keep spending it for hundreds of years after any nuclear power station has stopped producing electricity. Nor can we rely on the companies concerned to pay for the clean up afterwards; companies can go bust ... especially when they are no longer making money because no more electricity is being produced. Our children, our grandchildren and generations to come will then be left to pay for the problem of any nuclear power station we allow to be built in Wales.

There's a political dimension to this story, which I'll save for later. But as this article in today's Western Mail reminds us, our farming industry is still suffering the consequences of Chernobyl. And as this story only last week from Belgium illustrates, the radioactive cloud might well have claimed several victims of cancer even there.

Scotland finally catches up

From today, people in Scotland will get their prescriptions for free. This brings them into line with what we in Wales did first, followed by Northern Ireland. This graphic from the BBC story will save a couple of sentences of explanation:

     

But I also read the Channel 4 version of the story, which included this:

... from research in Wales, there is an indication that access to free prescriptions results in more people receiving medication.

In Wales they have witnessed a year-on-year increase in prescriptions dispensed by GPs of between four and six per cent since the reduction in 2000-01 and the eventual abolishment in 2007. A further rise of 3.3% has occurred over the last year.

Channel 4 News, 1 April 2011

Channel 4 News is usually the most reliable of sources, but this is an example of taking something that's undoubtedly true, but drawing a wrong and intentionally misleading conclusion from it. In fact it's precisely the same tactic as was continually used by the LibDems to criticize the abolition of prescription charges in Wales, for example here:

Commenting on the 5% increase in items claimed on prescription, Jenny Randerson, Welsh LibDem health spokesperson said:

"We warned the Government that giving free prescriptions for all would be disastrous and today's figures have vindicated our position. Three million extra items claimed in the last year is a direct result of this policy."

Jenny Randerson, 19 August 2008

Yes, it's true that the number has risen and is continuing to rise. But exactly the same is true in England. This is what I wrote about it on the WalesOnline forum some while ago:

The number of prescriptions dispensed in Wales has gone up steadily year upon year, while the cost has step-by-step gone down. Last year, the increase was 5%.

     Welsh Government, 2008

The number of prescriptions dispensed in England went up steadily by 55.1% over 10 years (roughly 5% a year), and is expected to rise by 5% each year, even though the cost has step-by-step gone up.

     NHS Information Centre, July 2007
     BJHC & IM, March 2006

Result? No correlation between the price and the number issued.

WalesOnline Forums, 9 April 2008

And to those who say that it is right for those who can afford to pay for prescriptions to do so, I completely agree. Our four national health services are funded by taxpayers, and richer people pay more in taxes than those who are less well off.

If you don't trust politicians, trust GPs

One of the features of the Yes for Wales campaign has been its decision to use people form all walks of life, rather than just politicians, to explain why we need to get out and vote Yes on 3 March. The reasons for that are quite understandable: people's level of trust in politicians is probably only marginally above our trust in estate agents ... although this survey shows that we do trust our AMs more than we trust our MPs.
     
But one group we are much more likely to trust is our GPs. So with only a week to go before the big day, it's good and very timely to see this endorsement of a Yes vote from Dr Andrew Dearden, chair of the Welsh Council of the BMA.

“For me, the question is about the most efficient and effective way for the Assembly to function.

“At the moment we have a half-way house. If we want to do something we can either do it or we have to got to Parliament in London and ask their permission.

“This question is different to whether you agree to having an Assembly. I would not want people to vote as to whether they want an Assembly. Since we have got one, it’s about how effective you would like it to run.”

Dr Dearden said that in his experience there have been many positive things that had come from devolution for the healthcare profession.

He said: “We keep asking ourselves how has the health of the people of Wales improved, but the health of the people is down to many factors that are not controlled by the Assembly.

“But there have been some very good things that the Assembly has done. They are leading the world on autism and they were the first nation to introduce the smoking ban.

“They are also looking into the transplant process and the issue of presumed consent.

“They have kept free accommodation for junior doctors when they come out of university, which is sensible for the economy as it will increase recruitment in Wales. It’s not a utopia, but they have kept things out that have been going on across the border."

South Wales Echo, 23 February 2011

He strikes quite a welcome note of realism. Getting some of the same primary lawmaking powers that Scotland and Northern Ireland already have is not going to transform Wales into a utopia. And it is true that many of the decisions any future Welsh Government will make on the health service will be about how wisely we allocate resources, not on what laws we can make.

But for some policy areas, making laws can make a very real difference.

Dr Dearden mentions the smoking ban—which we in Wales could have introduced much earlier without the present cumbersome system—and the issue of presumed consent for organ transplants. I could add to that by mentioning the new legislation on mental health, which I looked at in detail here.

The issue of presumed consent for organ transplants is a good illustration of an area where a majority in Wales want to change the system, but which the government in Westminster is refusing to let us do. As things stand they have an absolute veto, because the Assembly cannot legislate in any new area without permission from Westminster. But we can change that by voting Yes next Thursday.
     

Maybe in Manchester ... but not in Wales

Somewhere in David Jones' locker there must be a glimmer of perspective, but it's a long way down.

The Welsh Government has made no secret of its belief that stricter controls are necessary on alcohol. This is from a BBC report at the start of a consultation on drug and alcohol abuse more than two years ago:

Speaking at the launch of the consultation, Social Justice Minister Brian Gibbons said the economic and social costs of alcohol and class A drug misuse were estimated to be as much as £2bn each year.

"It also puts pressure on public services, costing the NHS in Wales up to £85m a year," he said. "It is therefore right we should place a greater emphasis on alcohol and reducing the harm it causes."

Wales' Chief Medical Officer Tony Jewell said the strategy would target younger drinkers. "There is growing evidence that young people in Wales are starting to drink at an early age and regularly binge-drink – with consequent risk of injury, road traffic crashes, unsafe sex and anti-social behaviour."

BBC, 11 February 2008

As things evolved—particularly with regard to the policy the Scottish Government has proposed—the Welsh Government reached a firmer position, which Edwina Hart presented in an oral statement to the Assembly in April this year. This is an extract:

In some ways, it is common sense that lower prices lead to more consumption. But there is now strong evidence to support this assertion – major reports produced by the Institute of Alcohol Studies, and by the University of Sheffield, have demonstrated that increases in affordability of alcohol lead to increases in consumption. They have also shown that increasing the price of alcohol will reduce consumption, particularly amongst young people, binge drinkers, and harmful drinkers who are dependent on alcohol. So we believe that there is now a strong case for the introduction of a minimum price for alcohol.

But what can we do about this in Wales? Our substance misuse strategy sets out our determination to tackle the harms associated with alcohol misuse, and commits us to press for robust action to tackle the availability of alcohol, including:

•  Stricter rules on the promotion of alcohol,
•  Consideration of reducing demand by introducing minimum pricing, and
•  Increased taxation, linking levels of tax more closely to alcohol strength

We do not currently have the powers to implement these changes ourselves. Our focus has been on making the case to the UK Government, and I and my Ministerial colleagues have written on a number of occasions to highlight these issues. And I believe that opinion is swinging our way. In recent months we have seen calls for minimum pricing from the BMA, the National Institute for Health and Clinical Excellence, and the Parliamentary Health Select Committee.

Oral Statement on Alcohol Pricing Policy, 27 April 2010

So it shouldn't have come as any real surprise to David Jones when Edwina Hart wrote to the Welsh Cabinet asking to set in motion a process for devolving such powers to Wales. But it was. As we can read in this report today:

But Mr Jones told BBC Radio Wales that they were "rather surprised" about Mrs Hart's announcement, as alcohol licensing powers were "specifically excluded" from the devolution settlement.

Well, if they were already included, there wouldn't be much point in making a request, would there? For it is something that is outside the scope of the GoWA 2006.

-

But to my mind, what he goes on to say displays an even greater degree of political ignorance:

Mr Jones said he would object in principle to powers on alcohol being devolved. He said the matter should be "properly dealt with on an England and Wales basis".

"Differential regimes could lead to so called alcohol tourism whereby people who live in Wrexham could go to Chester and do their alcohol shopping for a different price," he said.

If he—or even one of his researchers or a Wales Office special advisor—had read the Daily Telegraph a fortnight ago, he would know that local authorities in and around Manchester are intending to propose a minimum price on alcohol:

Manchester attempts to impose minimum price of alcohol

The ten local authorities in and around Manchester hope to pass a by-law that would set a minimum price of 50p per unit of alcohol, in an attempt to end to the cheap deals blamed for drink-fuelled disorder and health problems. It would affect all the pubs, supermarkets and off-licences in Manchester, Bolton, Rochdale, Oldham and the area covered by the The Association of Greater Manchester Authorities (AGMA), which has a population of 3.9 million.

This move would be far bolder than proposals by the Coalition Government, which have so far suggested investigating the banning of below-cost selling. A consultation has started to ascertain how to define "below-cost".

The Manchester idea has been pioneered by Our Life, an NHS-backed campaign group, which says North West England has one of the worst alcohol problems in the country. Andy Walker, at Our Life, said: "There are 1.3 million adults in the North West who drink hazardous or harmful amounts of alcohol. And the cost to the NHS North West, in terms of treating alcohol-related injuries and illnesses, is in excess of £400 million a year."

Daily Telegraph, 2 August 2010

So we see Manchester, an area with a very similar population to Wales, wanting to locally control alcohol pricing for its citizens in the same way as we want to do in Wales.

Now if the Tory party were being consistent, they would have dismissed Manchester's initiative out of hand. They would say it was illegal. They would say they were against the idea "in principle". They would point out that:

"Differential regimes could lead to so called alcohol tourism whereby people who live in Wrexham Manchester could go to Chester and do their alcohol shopping for a different price."

They might even go so far as to proclaim that:

"Laws over it would never be devolved."

But the Tories didn't do that in the case of Manchester. In fact they did precisely the opposite.

Despite retailers and the alcohol industry insisting Manchester's attempt stood no chance of passing the first legal hurdle, the Home Office said it was supportive of the idea.

A Home Office spokesperson said: "We welcome initiatives from local authorities especially when they are responding to the concerns of local people."

The lesson to be learned? If you represent the "local people" of Greater Manchester, the Tory/LibDem Government is all in favour of listening to your concerns and will support your initiative. If you represent the "local people" of Wales, that same government will not take any notice of your concerns ... and will dismiss your initiative out of hand.

Putting in and getting out

Today's story that less is being spent on the NHS in Wales than in England was headlined on the BBC website as:

     'Shock' over Welsh NHS underfunded compared to England

And indeed the political reaction is one of condemnation from opposition politicians and incomprehension from the BBC's reporters. But I think we are in danger of missing a more important point.

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If there's one thing that characterized Labour's thirteen years in power it was a huge increase in the amount of money spent on the health service. When they came to power, the health service was on its knees. It badly needed more investment, both in people and facilities.

But Labour's preferred mechanism for building new hospitals was PFI. Doing it this way had the advantage (until the accounting rules were changed) of keeping what would otherwise be public borrowing off the books. But funding new building projects in this way is much more expensive in the long term, not just because the consortia need to make a profit, but because of being tied to high-cost management and maintenance elements.

PFI was the norm in both the English and Welsh National Health Services until relatively recently. And the privatization ethos was even more evident when Wales bought into the idea of creating an internal market in our NHS to faithfully replicate what was being established in England. The existing Health Boards were broken into 22 smaller units precisely so that they could compete with each other over commissioning and providing services.

But both those policies were reversed in Wales. As a result of the One Wales Agreement, the internal market in the Welsh NHS was abandoned; and Welsh Labour—to their credit—had already come round to agreeing with Plaid on how expensive it was in the long term to build hospitals under PFI agreements. But there was a downside to this decision. In the absence of an alternative funding mechanism, the result was that fewer hospitals and clinics were built in Wales; but the ones that were built were financed in the normal way out of the capital investment element of the block grant. The Treasury would have been more than happy to allow Wales to build more hospitals, but only if funded under PFI ... as was still being done in England.

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Now why did we make these decisions? Simply because we knew that in the long term it would be much more cost effective not to use PFI. So if we imagine identical new hospitals in Wales and England, the one in Wales will cost our NHS very much less than the one in England ... maybe as little as half over a typical 25 or 30 year PFI contract. Similarly, the reason for abandoning the internal market in the NHS was to cut out waste and unnecessary duplication.

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Returning to the story, I don't know how much of the difference in funding between the Welsh and English NHS is down to factors such as this, but it should be quite clear that the intended result of doing what we have is for the Welsh NHS to cost us less than its English counterpart. The whole idea is to get the same outcome for less money (... or a better outcome for the same money). In other words, it is not just a question of over or under-funding compared with England or any other country, but a balance between funding and outcome.

Now perhaps our outcomes in Wales leave a lot to be desired—although it is worth remembering what Betsan Powys said here about the apparent differences in waiting times between Wales and England, and what I said about it in the context of the larger picture here—but we cannot naïvely assume that spending more money is the only way of improving these outcomes. It is not merely a question of how much we spend, but of how wisely we spend it.

I guess that's why they call it the blues

Wales' new NHS uniforms are being rolled out for the first time today in west Wales, and they are of course a good thing. But I was bemused by this description of the colours on the BBC website:

•  Hospital ward sisters/charge nurses and their deputies - navy blue
•  Clinical nurse specialist - royal blue
•  Staff nurse - hospital blue
•  Staff midwives - postman blue
•  Healthcare support workers - green
•  Nursery nurse - aqua green

BBC, 8 April 2010

I don't think anybody will have trouble with navy blue and royal blue ... but what on earth are "hospital blue" and "postman blue"?

Will be at all helpful to say to a woman who's just arrived at hospital after her waters have broken, "Just wait here a moment, the midwife will be along soon. You can't miss her, she'll be the one in postman blue"?

And yet, even though she will have no idea of what that colour might be, she couldn't help but marvel at the logic of putting the person in charge of deliveries in postman blue.