All posts by northlondonhousewife

Healthy 20

The NYTimes has just run an article suggesting the health habits worth picking up in your 20s, to serve you well in later life. It’s so obviously true that youth is wasted on the young, and also that believing themselves immortal, no 20 year old ever cared enough to take this advice, yet I will persevere and run these ideas past my daughters just in case:

 

 

Staying healthy in your 20s is strongly associated with a lower risk for heart disease in middle age, according to research from Northwestern University. That study showed that most people who adopted five healthy habits in their 20s – a lean body mass index, moderate alcohol consumption, no smoking, a healthy diet and regular physical activity – stayed healthy well into middle age.

 

So the healthy 20s list goes something like this:

Weigh yourself often – I am conflicted about this one, which probably says more about my own issues with my weight than anything to do with either healthy advice or my children. The advice given is to buy a bathroom scale or use one at the gym and weigh yourself regularly. There is nothing more harmful to long-term health than carrying excess pounds, and weight tends to creep up starting in the 20s. It is pretty easy for most people to get rid of three to five pounds and much harder to get rid of 20. If you keep an eye on your weight you can catch it quickly. At the same time, a later piece of advice is to practice portion control ie. be aware of what you’re eating and max out on the fruit and vegetables whilst moderating sweets. alcohol and processed foods. Maybe I could summarise this as “be aware”.

Learn to cook – My daughters know how to cook, how to follow recipes and how to put together a meal. They’re not experts but they’re on the path to a whole level of enjoyment. The official advice of course was less focus don enjoyment and more on “Learning to cook will save you money and help you to eat healthy. Your focus should be on tasty ways to add variety to your diet and to boost intake of veggies and fruits and other nutrient-rich ingredients”. Hmm. L:et’s add in a bit of advice to stay away from anyone who hasn’t bothered tolerant to cook. If they’re male, it speaks to an upbringing steeped in the patriarchy that no daughter of mine needs to deal with in her life. If they’re female, they’ll expect you to nurture and look after them whilst I see that as something they should do for themselves.

 

Cut back on sugar- The next advice was to try to avoid excessive simple sugar by eliminating the most common sources of consumption: 1) sugared soft drinks 2) breakfast cereals with added sugar and 3) adding table sugar to foods. My advice would probably be something along the lines of “know your sugar” ie. a bit of cake at teatime isn’t going to kill you but be aware of hidden sugar, casual pointless sugar that isn’t really adding any value such as soda drinks. Excessive sugar intake has been linked to obesity and diabetes, both of which contribute to heart disease.

 

​Live an active life – Build physical activity into your daily life. Find a way to get 20 or 30 minutes of activity each day, including riding a bike or briskly walking to work. While many people can’t find time for a scheduled exercise routine, that doesn’t mean you can’t find time to be active.

 

 ​​Eat your veg – My kids have been brought up to eat a range of vegetables and it would be sad to see that variety disappear. Nutrition science is complicated and debated endlessly, but the basics are well established: Eat plenty of plant foods, go easy on junk foods, and stay active. The trick is to enjoy your meals, but not to eat too much or too often.

 

​Adopt a post-party exercise routine – If you engage in a lot of drinking and snacking, ensure you exercise a lot to offset all those extra calories from Friday to Sunday that come with extra drinking and eating. We found in a study that on Friday through Sunday young adults consumed about 115 more calories than on other days, mainly from fat and alcohol.

 

​Find a job you love- Ohio State University research found that work life in your 20s can affect your midlife mental health. People who are less happy in their jobs are more likely to report depression, stress and sleep problems and have lower overall mental health scores. I want my kids to find a job they feel passionate about. This passion can keep them motivated, help them find meaning in life, and increase expectations about their future. That in turn will make them more engaged in life and healthier behaviors, which will have long term benefits for their well-being.

 

Divorce

All of my life I have worried about money, not in a “desperate to make it” kind of way, but rather desperate to have enough, just enough. And then you ask yourself what enough might mean and for me, the answer has always been “enough to walk away”

Money is a means to an end, and the end is independence. When I tell my partner that everyday I wake up and decided whether to stay or to leave, he laughs. Various friends and acquaintances are shocked or even horrified, and I’ve never really understood why. Surely at some level this is something we should all be doing, would all be doing if we felt we had a real choice. Who wants to share their life with a partner forced into keeping them company? What would that say about them and their relationship, less a partnership than a commercial enterprise.

And now with a friend trapped in a loveless marriage, not by money but by ties to her children, I’m made aware that money cannot of course solve all of the problems. She loves her children, not so much the husband who (for all she makes reasoned explanations of his behaviour, stress, pressure at work, sick parents) treats her like shit on his shoe far to often. Her own parents divorced when she had just gained independence and she found it traumatic. She wants to delay that trauma for her children until they’re older, until at least they have left home for university.

And so she puts up with him. She tells me it’s not so bad “He’s away a lot” and the rest of her life, the bit without him in it, is good. But she also worries that her kids will start to normalise their father’s behaviour and see this as an acceptable way to treat women, that the violent arguments when he’s around will impact their own emotional well-being. Is it better to stay or make the break, for the sake of the children?

When her youngest boy starts to swear at her and treat her with contempt, is it teenage hormones or a child copying the way he see’s his father behaving? When she points out to the child that he doesn’t like it when his dad treats him like this (apparently not uncommon) so why would he behave this way to her, he apologises and they move on. Is it enough to call it out for what it is, family bullying, a pattern of behaviour you don’t want to travel down the generations?

When her oldest boy is stressed out by exam pressure compounded by his father’s extreme expectations (Oxford Maths or a failure) and seems to be suffering from an eating disorder, what do you do? Is it better to hope that he succeeds and gets out of the house to sunny Oxford, or that it all fucks up early and he get’s some help in rebuilding himself the way he’s happy with not his father’s mini-me?

Four years is a long time to live miserably.

His retirement is just around the corner. Will it make the situation bitter or worse? Without the kudos of a big, well-paying job, what will this mean little man do to prop up his ego? He could just relax into the swing of his “third-age” playing golf, taking up some voluntary work and chilling out. It might well be the making of him and possibly his marriage.

I couldn’t forgive him. I couldn’t let go of the spite, the nastiness. Not for ten years or more. Whatever the reason, and I’m sure he has many, there’s no need to bundle up all of that anger and use it to hit out emotionally at your partner, your helpmeet and friend.

I couldn’t stay, not for a week never mind four more years.

At least when it’s over, she has enough money to walk away. Most women don’t.

Barbara Reeves, a partner at Mishcon de Reya, has decades of experience in family law. She says risk is inevitable in divorce – and managing it is crucial. “There is a perception that women in England do well out of divorce – with London being described as the world’s divorce capital,” she said. “But it’s important to remember that if this is the case, it is only so for the wives of the super-wealthy. The reality for most women is that they have often created homes, raised children and supported their partners while their own careers have stood still, or progressed at a considerably slower rate.

“The money these women could have earned – and consequently their potential to save for their own future long-term needs, including retirement – has been significantly compromised.

“Divorce has always been a daunting prospect for the financially weaker party, and historically this has been the woman. It is not so much the cost of the proceedings that is daunting – but the aftermath. As the CII report shows, typically it’s women who absorb the risk: those in middle age can find themselves unemployable in an industry they may have thrived in before their marriage and/or having children.

“Once their children have grown up and any maintenance payments begin to dry up, they are often forced to rely on state provision. As Sian Fisher of the CII points out in the report, the historic support systems are receding: ‘We’re all expected to look after ourselves. On top of this, [women] may be caring for elderly parents and contending with their own mental or physical health issues.’ ”

But Reeves adds: “Divorce is a far less daunting prospect for women than non-marital separation: we still see women who have spent decades as a homemaker, raising children … being forced to walk away at the end of their relationship with nothing. If she was married, the ‘homemaker’ has a right to share a partner’s pensions. However, this is a share of the pension assets at the time of the divorce.

“Following divorce, the financially stronger party – historically the man – can continue to earn at his full earning potential and top up his pension pot; meanwhile, the woman may have a reduced earning potential following years out of the employment market while she was building the home and bringing up children. And for women who are unmarried, there is no entitlement to a share in their former partner’s pension. Risk is inherent in relationships for women. While the gender pay gap between men and women in their 20s has closed, the gap opens and widens in later years – in quite a significant part because of women taking time out of employment to have families.”

A relationship, she went on, is the biggest financial risk women take. “Any woman embarking on a relationship should at least hear the facts and be aware of the risk she is adopting.”

Cheese Soda Bread

Soda bread is the easiest bread recipe I know, especially this one with floury potatoes added in for extra oomph. Makes one large loaf

25g butter
1½ tbsp light brown sugar
1 small bunch lemon thyme, leaves picked, plus a few extra branches
2 leeks, trimmed, washed and cut into 1cm-thick rounds
1 pinch cayenne pepper (optional)
100g extra-mature cheddar, finely grated
250g maris piper (or other floury potato), peeled and cut into quarters
300g plain flour, plus extra for dusting
300g wholegrain spelt flour
1 tsp bicarbonate of soda
1 tsp fine sea salt
568ml buttermilk (ie two large pots)
40g parmesan, finely grated

Heat the oven to 200C/390F/gas mark 6. Heat the butter and sugar in a large frying pan, season generously with salt, pepper and the lemon thyme, then saute the leeks for 15-20 minutes, stirring from time to time, until sticky and caramelised. Leave to cool and, once completely cool, stir in the cayenne, if using, and all but a tablespoon of the cheddar.

Meanwhile fill a small pan with cold water, add the potatoes and bring to a boil. Simmer for 10 minutes, until tender, then drain and leave to steam dry in the pan. Once dry, mash and leave to cool.

Lightly flour a clean work surface. In a large bowl, mix the flours, bicarb and salt. In a second bowl, lightly whisk the leek mixture through the buttermilk. Make a well in the centre of the flour bowl, then pour in the leek mixture and whisk to combine. Tip out and knead briefly, just until the dough comes together: the more you work soda bread dough, the heavier it will be, so the quicker you can get the loaf into the oven after mixing the wet mixture with the dry, the better.

Shape the dough into a ball and put on to a floured baking sheet. Cut a deep cross into the top of the dough with a very sharp knife, then dust with flour and scatter with the remaining cheddar and parmesan. Press the remaining branches of lemon thyme into the loaf.

Bake for an hour, until the loaf is cooked through. To check that it’s done, turn the loaf over and tap the underside: once cooked, it will sound hollow. If it still sounds solid, pop the bread back in the oven for 10 minutes more, then test again. Leave to cool before tearing apart and serving with a crisp salad and a plate of cheese and ham.
Thomasina Miers’ cheddar, leek and maris piper soda bread.

Looking Forward

By the end of this month, perhaps as early as next week, the prime minister will have signed and dispatched a letter notifying the European Council of Britain’s decision to leave the European Union through the provisions of article 50 of the Lisbon treaty. There will be no turning back. The most serious negotiation in our post-war history will commence. It must conclude within two years – unless the remaining EU member states determine that the negotiating period can be extended. It will shape our new settlement for decades to come.

It has been suggested that there is a 50:50 chance that no deal will be struck and the UK will bounce out of the EU onto WTO rules only. The UK government as represented by David Davis and Boris Johnson could not even bring themselves to agree as to whether any contingency plans for WTO rules were being in put in place on Sunday.

At this juncture in our history, we face a crucial choice. Will this be a moment for national renewal, where we courageously confront our problems, or will we simply attempt to muddle through? Nothing would be more British than the latter – and that would appear to be where both sides of the Brexit divide are taking us. I am now entirely convinced that whilst we are where we are, none of the leading “out” campaigners currently in government, and certainly none of those in government who campaigned to remain, believe that brexit is going to be good for the country.

As time has passed, committed brexit campaigners such as David Davis and Liam Fox, have come face to face with the many many complexities staring them in the face as part of the negotiations, not least of which is managing the still rand expectations of some Tory back-benchers.

So if the government is increasing aware of the looming disaster, and is with the best intentions set upon mitigating the disaster whilst delivering on the referendum mandate, what happens next?

We muddle through. We pay the price for a poor decision to call a simple referendum on a complex questions after years of demonising and blaming the EU for UK government mistakes and unpopular decisions.

But there is also a case for the other approach – for using Brexit as a moment to bring about the change that Britain needs. If we are to embark on fundamental changes, we must first frankly acknowledge our problems. The rancour over the referendum, plus the fundamental ambivalence by the people who won the vote makes the acknowledgment of problems near impossible but it is the only way to make something positive, to turn the sow’s ears into silk.

Seeds

In my dreams my garden is elegant and restrained. It might even be one of those beautiful white only “outside rooms” that people talk about.

In reality, my garden is pretty. It has too many plants and too many colours to come even remotely close to “elegant”.

Salvia viridis syn S. horminum ‘Oxford Blue’ – annual clary

And yet every year I seem to find more space to cram in yet more flowers. This year I’m happy to have planted some mini-narcissus under the hedge and it’s looking good. There’s still a gap on the fritelaria bed so there’s some more room free for planting up bulbs next Autumn.

Nigella hispanica ‘Midnight’

 

But what I have never really invested in are seed catalogues yet this year they’ve arrived and there is some space around the new roses to be filled.

Papaver somniferum ‘Black Peony’

In the end I’ve decided that nigella will grow and look good against the pale pink roses. maybe they’ll form one of those artistic elegant drifts but probably not. Having done this before with nigella, I do know that if I scatter the seeds about, they’ll certainly grow and grow.

Zinnia elegans ‘Luminosa’

 

In fact it’s likely to take years to get rid of the beggars if I decide that I don’t like them after all. I’ve dabbled with the idea of zinnia or salvia.

Zinnia elegans ‘Benary’s Giant White’
Cosmos bipinnatus ‘Double Click Cranberries’

And who wouldn’t love cosmos growing in their flower beds.

Cosmos bipinnatus ‘Fizzy White’
Cosmos bipinnatus ‘Purity’

Poppies and nigella are on their way. The sweetpeas are about to be planted in their coir pots and all is well with the crocus and narcissus sparkling bright and sharp amongst the greenery.

This is going to be a good year for the garden.

Citrus Pickled Veg

Bright tasting and fresh, these pickled vegetables can be used as a side dish for cold beef above or any main course.

Enough for 4 as a side salad

carrots 3 medium
mouli/whiteradish half
radishes 8
shallots 3
lime 1
oranges 2
lemon 1
white wine vinegar 2 tbsp

Peel the carrots and the mouli and slice them into very thin rounds. Slice the radishes, too. Peel the shallots and cut them into quarters, toss the radishes and shallots gently together and place in a shallow layer in a mixing bowl.

Make the dressing: squeeze the lime into a small bowl, add the juice of the oranges and the lemon, then stir in the white wine vinegar. Season with a generous pinch of salt. Pour the dressing over the sliced vegetables, then cover with cling film and leave for at least 3 hours. They should be bright, crisp and slightly sour.

Pickled vegetables

Retirement

Their dad tells me he’s going to retire at the end of the year. I’ve told him that he should have a plan. The words of a friend “You marry for life, not for lunch” echo around.

My life is essentially organised around having fun, with a bit of fund management thrown in for good measure. I play tennis and bridge with friends, visit galleries, go to the theatre, organise and undertake some wonderful travel (Peru and Bolivia later this year) look after my nearly grown kids and throw in a bit of financial fund management to finance it all. Most days have an organised schedule but nothing that couldn’t be cancelled at the drop of a hat or the call from school.

So when he finally stops work, looking to me to provide entertainment is likely to a waste of time. My life is already quite busy and whilst we can probably rearrange things to spend a couple of mornings or afternoons doing something together, we’re not going to be each others be all and end all activity.

According to an article in the Guardian today, there are a couple of things to avoid when you retire:

Unsuccessful retirements have two main characteristics, either they tend to atrophy or they do too much: they take on too many responsibilities or they fail to put boundaries in place to stop their families demanding too much from them.

Successful retirements nearly always involve a plan:

David Kelley runs a pre-retirement course in a quiet office in central London.Distilling Kelley’s decade of expertise down to a core lesson isn’t easy but the phase “proper selfishness” jumps out. “We have to start thinking like a two-year-old when we’re thinking about retirement,” he told the group. “We get forced into adaption throughout our youth and our working lives. Now we have to get out of that habit and into one that says ‘me first’.”

Obviously many people are faced with both financial and health constraints which will have to be managed. We’re lucky, with both of us having savings and pensions in place and no obvious health issues on the horizon.

Studies show that retired people waste a great deal of time deciding what they are going to do with the rest of their lives. At 65, a man can expect to live 25 more years, and a woman 27. But they can also spend up to 15 years post-retirement reorienting themselves: just 56% say they enjoy retirement “a great deal” during this period, and just 57% feel it is working out as they planned. So it’s important to have an idea of what you want to do before you actually retire.

Apparently There are four basic factors that make for a successful retirement:

  • By far the most important element is a person’s social network. Entering retirement with only your immediate family and your work network is a frequent cause of retirement depression which can be a downward spiral that is very difficult to reverse.
  • Having purpose and challenging one’s mind is the second element. This usually takes the form of some type of work – whether paid or unpaid.
  • Ongoing personal development should never stop a factor highlighted by the recent rapid increase in mature learners and the boom in retirement learning and development services
  • The fourth element is a serious one: to have fun.

Obviously, looked at through a slightly different lens, the elements of a successful retirement are no different to the elements of a successful life.

David Kelley himself has no intention of wasting his time. Immediately after he retired, he wrote himself a business plan for the rest of his life. It read: “Two days earning. Two days learning. Three days just for me.” There are two addenda: “Don’t be afraid to say no,” and “Don’t travel anywhere before 10am.” “I hate the rush hour,” he explains.

 

Elite

There was an excellent article in the Spectator by Matthew Parrish that I have decided to take to heart. I have decided to enjoy brexit going forward. This does not mean I agree that it was a good idea, in any way shape or form. I think we’re fucked. I genuinely believe that we have taken a turn in the wrong direction and millions of British citizens will be poorer as a result.

But that’s not on me. That’s entirely the responsibility of those people who voted “leave” and I’m not one of them.

So when the discussions turn to the rights or otherwise of British citizens living in the EU, I am calm. I have done my best for them. I voted “remain” to maintain their rights so the current turbulence, the lack of security and serenity is entirely due to “leave” voters.

Maybe all of the many many pitfalls and pratfalls I see opening up in front of our country will never come to pass. It’s possible that pessimism is overstated.

But each and every time something goes wrong, I can clearly and easily acknowledge the fact that this is not my doing. I did not vote for this. And if you did, well shame on you because you were definitely warned.

Best Intentions

The Comptroller and Auditor General in the UK and England is an old post that came into being in 1866. Now as the 17th occupant of the office,  is to head the National Audit Office (NAO) and to support Parliament in holding government to account for how departments and agencies spend public money.  He has just published a report on the LSE site

He explored some of the elements of strategic financial management and planning, a potentially dry topic but ultimately one that determines success in any major government reform programmes. His specific context was how central government introduces reforms to locally delivered services so as to achieve its policy objectives, and the effect of its approach on funding, budgeting and efficiency.

There is a strong case for considering this area in the light of recent practical experience, alongside the problems created by a lack of joined-up thinking.

He said nothing particularly surprising, or anything that any of the senior figures involved would argue with, though they might not like his conclusion. He did not challenge any policy objectives nor the basic principle of seeking to use public resources as efficiently as possible and make economies where possible. He talked about the ‘how’, not the ‘what’ – in short: intelligent implementation and its context of budgeting and funding.

He set out the fundamental issue. The examples of connected systems used were local government, adult social care (delivered by local government) and the National Health Service in England.

The policy background is that since 2010 central government in Whitehall has been progressively ‘freeing’ local government from central government by first the push for localism and culminating in financial self-sufficiency; then English devolution plans to transfer more services to local government, including health, along the lines of the ‘Greater Manchester model’; and there has been a desire to drive up quality and manage the health needs of an aging population.

Underlying everything has been the Government’s austerity agenda.

Joined-up decision-making and funding arrangements between connected systems – central government and local bodies for instance – have often been missing, leading to deleterious consequences. Within these connected systems, this gives rise to:

  • unforeseen conflicting objectives for local bodies;
  • cost shunting between parts of connected systems; and ultimately
  • risks of financial, or service, failure locally.

Central government has been slow to adjust – often acting only when serious failure occurs.

Part of the reason for this is an ‘out of sight, out of mind’ culture. It is relatively easy to for central decision-makers to allocate savings to be made by those operating outside a department’s boundary or with a different mandate, without necessarily understanding their effect. When public sector decision-makers are making big decisions and cost reductions, they need to be able to validate those decisions very well and they haven’t.

Decision-makers have an obligation to have good evidence, to have explored the secondary effects of their potential decision, and to have explored the downsides. They need to take a ‘one government’ approach – including local government – to managing the overall government finances for the best overall outcomes. Without this, the consequences of hasty decision-making have come home to roost, sometimes quite quickly.

Local government

He looked at some examples. Since 2010 central government has progressively cut support to local government, meanwhile giving it new powers including a general power of competence under the Localism Act. More recently, DCLG took the first steps towards local government retaining 100% of business rates by the end of this Parliament, making local government ‘financially self-sufficient’.

But the ability to retain local taxes must be set against background where local authority spending power – covering the day-to-day costs of running services – fell by around 25% in real terms from 2010 to 2016, with another 6% cut in spending power planned up to 2020.

The inference and expectation was that there is waste in local government so more could be delivered for less, and local government will be able to generate its own income through fees, charges and commercialisation schemes.

At the beginning, local government responded with new, more efficient ways to deliver services. However, over time this has shifted from ‘more for less’ to ‘less for less’.

This is because, during this progressive reduction in funding, there has been no evidence-based effort to reconcile funding to local needs. The policy objectives for local government and the local government statutory duties have not been properly weighted against potential efficiency savings. The 2015 Spending Review made some headway here but it was not a comprehensive approach. Accordingly, what we see are ‘deficit behaviours’ such as:

  • the invisible rationing of services; and
  • quiet drops in service quality.

Users are now coming into the system later with greater needs. These are local councils’ only real options to square the circle as they are prevented by law from going into financial deficit or to borrow to fund revenue spending. This has obvious direct effects on service users, but also reduces local government resilience, and its ability to contribute discretionary resources to central initiatives, however attractive. But those ‘deficit behaviours’ are hidden, since there are few local government sector-wide leading indicator statistics to give a clear indication that the system is in distress and where the gaps in services are occurring.

NAO reports into this area tell us that there have been large, real-terms, planned reductions in spending between 2010 and 2015, for instance reductions of:

  • 36% for cultural services;
  • 47% for housing services; and
  • 53% for planning and development.

Once funding passed directly to schools is removed, it becomes clear, however, that local authority expenditure is dominated by social care for both children and adults. Local authorities have also sought to protect spending on social care because of the high number of statutory responsibilities that they have.

Nevertheless, there has been an overall 7% real-terms reduction in spending on adult social care by local authorities between 2010 and 2015. And areas with the greatest needs lost the most. Besides the direct effect on care service users, this reduction has a destructive effect on the NHS, which is, in part, highly connected to the social care system.

Costs are effectively being shunted from one part of the connected system to another. For instance, hospitals’ ability to discharge patients with care needs on time is affected when patients who are not supported to live independently tumble into A&E and acute health provision – a leading indicator of primary care and social care shortfalls.

That is not the whole story for the health care system however. Since the introduction of the Health and Social Care Act 2012 – the Lansley reforms – there have been significant changes to the NHS. These were, and are, aimed at improving patient care at a time of rising demand.

Again, in addition to the reforms themselves, this was at a time when there was, as with local government, an agenda of increased financial pressures arising from austerity. And again, the implication – that there was slack in system and more efficiencies were possible.

For the NHS, this came in the form of the ‘Nicholson challenge’, named after the former NHS chief, Sir David Nicholson. The parameters of the ‘Nicholson challenge’ collectively added up to a demand for the NHS to find £20 billion in efficiency savings by 2015 to close the gap between need and available funding.

The latest iteration of which is the Five Year Forward View, which assumes that the NHS will deliver a further £22 billion of efficiency savings out of a flat real budget. Initially the Government had an efficiency target of 4% but this was reduced to 2% in 2016-17 – which was deemed a more reasonable requirement.

Nevertheless, over the entire period, the financial position of NHS bodies has continued to decline.

The number of trusts in deficit has steadily risen. 66% of NHS trusts and NHS foundation trusts are now in deficit. Ironically, these trusts were selected a few years ago for foundation status because NHS England assessed them as independently financially viable.

Where deficits become the norm, trust managers no longer feel ‘singled out’ and they probably worry more about the hard-nosed judgements delivered on health care standards by Care Quality Commission.

The Care Quality Commission has led a drive to name hospitals that were not operating to the right standards. In these circumstances, unreconciled pressures face hospital chief executives, many of who are highly experienced, highly skilled managers. The implementation approach for both efficiencies and reforms did not take a full and realistic account of the context within which the healthcare system was operating. The implementation approach also failed to consider the result of other policies being put into effect simultaneously.

As early as 2014 there were a number of ‘leading indicator’ statistics – including cancer referral to treatment times and ambulance response times falling below national standards – showing the system is quite clearly struggling to cope. In short, service standards are under strain, as is the financial sustainability of our health care system.

Rather than heed the early warning signs, however, ministers appeared largely to plough forward with their efficiency regime. The government introduced a range of further initiatives that it wants the NHS system to take on-board, including the seven-day service and new strategies for cancer and mental health. All of these may be, no doubt, good ideas and desirable developments. But they represent signals to build demand in a system already under severe resource pressure.

There has been no real dialogue between central government and healthcare bodies regarding the mix between rationing, efficiencies and services provided. The health service has, in fairness, attempted to do this with Sustainability and Transformation Plans for 2017-18, and this is accompanied by a front end boost in spending. This might have the effect of stabilising NHS England but the Plans, or Proposals as they are now called, are built around a forcing strategy rather than consensus. If they do not meet NHS England’s requirements in terms of matching demand with resource the trusts will lose money.

The political assumption remains that there is excess capacity that can be taken out of the system – or that demand can be made to fit the resources available. Perhaps such a position was true at a certain point, but who believes that it remains true? When was the clear point at which the number of trust in deficit became untenable and the system moved into a state of distress?

Of course, the centre of government cannot avoid making informed assumptions about efficiencies that may be available. However, they can do much more to understand how these assumptions are likely to affect government’s objectives, and to promptly manage major risks. That is why many of the recent audit reports highlighted the need to identify critical assumptions, work through their implications and monitor them closely. That is also why, since 2014, there have been a series of reviews of the financial sustainability of local services, including reports on local authorities, police forces, fire and rescue services and the health service. The aim has been both to help central government understand how changes in responsibilities and funding are affecting local services and to help identify and share good practice.

As an aside, it seems likely that the education system may be the next to experience these pressures. Schools have to make £3 billion in efficiency savings by 2020 against a background of growing pupil numbers and a real-terms reduction in funding per pupil. I hope that this will be much more closely monitored and managed.

Almost every conversation these days is dominated by brexit, but the implications will be felt long and wide. First, local bodies could be put under further resource pressure by the loss of EU funding streams to local areas with no specific plan so far to replace them.

Second, Brexit is highly likely to divert senior talent time and attention in quite a number of departments, never mind the diversion of talent into the main Brexit department and multiple trade deal negotiations of the future. In all likelihood, this means less senior talent time for resolving funding and reform challenges for local bodies.

Finally – and this hardly needs saying – local services are, to a significant degree, depending on workers from EU countries. Without EU doctors and care workers there could be further strain on the system unless alternative arrangements are in place.

Those in the centre can be a lot more agile about getting out of their silos and understanding the complex interlocking reform environment, recognising negative trends, and shifting their position quickly to limit damage.

In the examples described the reaction from central government has been slow, perhaps because of silo problems between spending departments and the Treasury, and there has been little real change of direction. Did the centre know, do they know now, when the boundary between mainly efficiencies, more for less, was crossed and we started into the territory of less for less?

Central savings may have been secured, but significant damage has been done.