Sick

Today’s post is prompted by the story this week that Hillary Clinton has had to take time off from campaigning because she has pneumonia. In fact, she only took four days off – which, frankly, seems very little to recover from pneumonia - but this has been seized on by her political opponents as evidence that she is not up to the job of US President.

Although the political reasons for this are obvious, it seems to me to fit with a wider issue of the way that in the UK, at least, going off sick is frowned upon, and worse. It can be taken as a sign of unreliability and lack of commitment. The Sports Direct scandal revealed exactly this, with sick leave being counted against workers, who as a result were too scared to take it. But that case is the tip of a much larger iceberg. A 2015 survey found that one in four British workers were too afraid to take time off when ill, and the study suggests that they are much less likely to do so than workers in some other countries: in 2015 8.9% of British workers took more than 8 days sick leave compared with 25.3% of German workers.

If we discount the idea that the British are inherently healthier than the Germans, then it seems obvious that what is at issue is the politics and culture of work. Organizationally, it links to the more brutal management and work conditions in Britain, including the precarious employment terms discussed in my last post. Certainly self-employed workers take about half as much time off sick as those in employment.

British politicians routinely berate the public sector in particular for having higher levels of sick leave than the private sector even though both have fallen steadily for the last 20 years according to the Office for National Statistics. But Stephen Bevan of the Work Foundation and Lancaster University Management School explains that this difference (7.9 days per year in the public sector versus 5.5 days in the private sector) can easily be understood. It isn’t that public sector workers are malingerers, but a combination of the demographics, the more risky occupations and the better recording of sick leave that exist within the public sector.

In addition to this, I think that there is a very macho issue around taking sick leave. This seems evident in the debate about Hillary Clinton illness but, more generally in the sense that it is somehow ‘soft’ or ‘wimpy’ to ‘give in’ and take time off. Real men power on through it. The UK statistics bear this out, with women losing 2.6% of working hours to sickness compared with 1.6% for men (2013 figures).

It seems unlikely to me that it is any better for businesses than for individuals to work when they are sick. They are likely to be less productive, and to infect other workers. With the weather in Britain today having taken a decisive turn to autumn, we are now entering the season of coughs and colds. Personally, I find it intensely unpleasant if the people at work, in shops or on public transport are spluttering and sneezing all over me. In 1945 there was a splendidly amusing public information film (you can see it here) warning that ‘coughs and sneezes spread diseases’ and instructing people to use a handkerchief. Well, that’s fine so far as it goes, but much better for all concerned to stay off sick until you get better, and for employers to support that.

Painful choices

There is so much that is painful in the world right now – events in France, Germany and Turkey come particularly to mind – that there is no shortage of things I might write under this heading. I don’t think I have ever known so depressing a time, politically, in my life. But in this post I want to focus on the particular and personal pain that I have been experiencing: dental pain. And more specifically some organizational things around that pain.

In brief, last week I developed a toothache and went to the dentist who booked me in for some treatment. Over the weekend the pain became truly agonizing – I’ve had dental pain before but nothing remotely like this – to the extent that I had to contact the out of hours doctor for some non-prescription painkillers. This process itself was organizationally painful, involving no fewer than five telephone calls, each one acting as a kind of filter. Thus on the first call I was asked a checklist of questions clearly designed to either put up red flags (‘Pains in chest? Difficulty breathing?’) or to process me to the right person.

There’s nothing objectionable about that, although I could see it leading to many false positives and negatives, except perhaps the fact that each subsequent phone call entailed repeating my symptoms and needs (in summary: ‘I’m in agony, give me some super-strong painkillers right now’ which maybe could have been passed on). But what struck me was that when it came to prescribing medicine I was told about various different possibilities and the downsides – for example potential side-effects – of these. So I asked whether or not I should take the prescribed medicine, although frankly I was in so much pain that I would have done anything, whatever the risk, up to and including amateur surgery. And the response is what I want to write about, because it was to say that what mattered was that I had been ‘made aware of the risks and so could make an informed choice’.

It seems clear to me that this has nothing to do with my making an informed choice and everything to do with organizational self-protection. If things went wrong, I could hardly complain: I had been warned of the risks. But I had no way of assessing these risks or calibrating them against the benefits and so the choice did not in any way empower me; rather, it disempowered me in the event of any problem that subsequently emerged. It reminded me of a point made in my recent book on secrecy where we argue that the ‘full transparency’ of the terms and conditions we sign up to when making online purchases is actually a form of secrecy. The T&Cs are so lengthy and complex that no one reads them or could understand them if they did, yet in the event of a problem or dispute we can be told that we had been given full information and had agreed to it by ticking the acceptance box.

Anyway, I took my medicine and all went well in that the pain was somewhat lessened and I had no unpleasant side-effects (on the contrary, a rather pleasant wooziness) and I went to the dentist again. She told me that I had a choice between having root canal surgery or an extraction and talked me through the pros and cons. A choice again, then, and this time not I think one to do with organizational self-protection but reflecting current understandings of professionalism in healthcare and other spheres. I say current understandings because in the past the norm was for health professionals to simply tell you what to do. It was a more authoritarian, paternalistic approach in which the doctor (or dentist) knew best.

That has now given way to a more patient-centred and, I suppose, consumerist ethos in which clinician and patient together make treatment decisions. The trouble is that I really don’t want this, and don’t have any basis on which to make a choice – and it is a particularly bad time to try to make choices when one is in pain. I would actually rather be told what to do: my choice is not to choose, but that wasn’t an option. So the conversation became an exercise in me trying to detect and provoke signals from the dentist as to what she actually thought was the best course of action.

It may seem a stretch, but I think this links to the post-truth politics I discussed in my recent post The Sleep of Reason where ‘expert’ opinion is derided and we have a mixture of a consumerist market for ideas and an implication that how passionately a view is held is in some way an index of its truth. For some, this is a liberation from the tyranny of authority, but it goes hand in hand with a breakdown in trust and a devaluation of rationality. Perhaps this has had some good effects. The deference shown to experts in the past was not always healthy – for example, I can remember my late father always dressing in his best clothes when he had to visit his GP which seems extraordinary to me. On the other hand, the idea that a few minutes on google can enable us to talk on equal terms with our doctors is even more bizarre. In the face of pain, at least, I am a positivist and I want someone with knowledge of the evidence to tell me what to do about it.

Oh, and for anyone interested the decision was to have root canal surgery, starting this Friday. It was my choice, but I reserve the right to moan about it. Pain does not just make me a positivist, it also exacerbates, if that is possible, my propensity to grumpiness, gloom and outright bad temper.

Ageing badly

There is plenty of public discussion of the complex issues involved in being a parent, but far less about having parents. What I mean is the issues arising for people in middle-age having to care for and cope with their ageing parents. Those issues are made more complex by the way that families tend now to be dispersed geographically and the much longer live spans that are now common. The consequence is the necessity of engaging with the organization of care for the elderly. In the UK, at least, that organization is woefully inadequate and in crisis.

Longer live expectancy is both a consequence of medical care and a cause of the need for medical care. This in turn requires increased health expenditure, but in 2015 the UK health expenditure as a percentage of GDP was 8.5%: lower than Greece, lower than most west European countries, and far lower than the US. Against this, it has to be recognized that the UK system is far more efficient than others in translating expenditure into health outcomes. Maybe more important, though, is that increases in UK health expenditure don’t match increased costs (healthcare cost inflation is much higher than general price inflation) and increased demand (driven primarily by ageing).

But healthcare is only one part, and not necessarily the most important part, of the organization of ageing. Most health expenditure arises in the last two years of life; whether that life ends at 70 or 90. No, the real issue is the organization of care, and this is in complete crisis. Whereas it used to be provided mainly by local authorities, now there is a hybrid system of private care homes part-funded by local authorities. Budget cutbacks mean that the part-funding is increasingly inadequate; whilst the crazy financial engineering of some private home owners like the collapsed Southern Cross (discussed on p.115 of the book) exacerbates the problem.

The two aspects of health care and care homes are closely related. Both emergency and routine care departments of hospitals can’t discharge elderly patients because there is nowhere for them to go, especially if they are ‘unprofitable’ from a care home perspective. On the other hand, as a report this week highlights, in other cases the elderly are being discharged back to their own homes when they are incapable of coping, with horrific consequences.

All of this is absolutely to do with failures in the way that we organize. The privatized, often private equity firm-owned care home system is simply absurd, and passes on its inefficiencies to the public sector NHS. But beyond that is the obvious absurdity of dividing health and social care at all. There has been much talk of overcoming it, and some areas in England have made progress in doing so but overall the separation remains stubbornly in place.

As is often – perhaps always – the case, the issues relate to both organizations in the institutional sense (the structures of, in this case, health and social care) and to ideational organization (the construction of ‘health’ and ‘care’ as categories). Underlying the latter is perhaps also the more profound division of the public and private realms, so that health care is something that happens in the public domain of the hospital ward and social care something that happens in the private domain of the home (even if the home is an institutional ‘care home’). This in turn means that much suffering remains hidden (‘at home’) and experienced by both the elderly and their families as a ‘private’ problem, and possibly a stigma.

The psychology of this is undoubtedly very complex, since the relations between (adult, ageing) children and (aged) parents has the capacity to engender guilt, frustration, anger, fear and much else besides. Psychology has been much concerned with the relationships of children and parents in infancy, but perhaps much less so (at least, that’s my impression) with those in adulthood. The dynamics of the latter are surely taking new forms as extended old age and associated dependency become the norm rather than the exception.

In 1911 in the UK life expectancy was 51 years; by 2013 it was 81 years. In 1911 there were 107 people in Britain aged 100 or over; in 2013 there were 13,780. A similar pattern can be found across the developed world. Organizationally, and emotionally, we have not really caught up with these profound demographic changes.

Intended consequences

In the book, I make much use of the concept of ‘unintended consequences’ – the way that, in particular, rational-legal rules give rise to effects that were not only different to those intended but run directly counter to what was intended. My last post on the VW emissions scandal provided a current example.

But sometimes the situation is more complex, and I return here to the case of regulations around smoking, about which I have written in another post on this blog, and, with Jo Brewis, also written an academic paper (Brewis & Grey,2008). The latest development is that today a law has come in to force banning smoking in cars when a person less than 18 years old is present in the car. It’s by no means an objectionable law, in and of itself, because who would want to claim that smoking in a car with children is in any way a good thing?

What is interesting about this law, though, is that it is manifestly doomed to failure. Police representatives have already said that it is unenforceable, partly due to lack of resources but also because of detection problems. For example, electronic cigarettes are not included in the legislation so a police patrol would not easily be able to tell whether an offence was being committed, nor is it easy to know the age of passengers from a patrol car. Moreover, the legislation allows 17 year olds to smoke in cars if the passengers are 18, allows smoking in convertibles with the hood down, and allows smoking in caravans and motorhomes, even if children are present, so long as the vehicle are not at that point moving.

We might, then, assume that the intended consequence is to stop smoking in cars with children and that the unintended consequence is it not working. But in fact the situation is more complex. The long-term aim of anti-smoking activists is the eradication of all smoking, but they approach this goal stealthily because smoking is such a strongly culturally embedded practice. From that perspective, the failure of this latest legislation will be desirable, because when it fails it will justify a new law banning all smoking in all vehicles in all circumstances.

Social science research is sometimes criticised for lacking the predictive power of natural science, so here I will make a prediction. Within, say, five years (and I would expect less rather than more) a total smoking ban in cars will be in force. And as soon as it is, or even, possibly, before there will be lobbying for a ban on smoking in houses where children are present. Once again few will object, because no one could really mount a case that it would be good to allow it. So a law will follow, which will of course be even more unenforceable than that against smoking in cars with children. From which will ‘logically’ follow that all smoking by anyone in any house will be banned.

By that point, the situation as regards public spaces (e.g. bars) and private spaces (e.g. homes) will be identical: smoking in both is banned. So what happens then? Well, look at what is happening around the regulations on public spaces. At first, it was just indoors. Now, it is increasingly in parks and on beaches which are public spaces but outdoors, including outside pub doorways. The rationale for this is not that others might inhale the fumes, but that those (especially children) seeing it might think that smoking was ‘normal’. So, once there is a ban on smoking inside homes, it will get extended to smoking outside home, for example in gardens. In other words, as each new rule ‘fails’, that failure provides the rationale for a new rule. It is in this sense that failure is an intended consequence of regulation since it paves the way for successfully extending regulation.

With smoking now very much a minority activity in the UK and many other countries, few will shed a tear about any of this (and it’s not my intention that anyone should: I just want to provide an interesting illustration of a particular phenomenon around unintended consequences). But it’s worth reflecting that with the campaign to reduce smoking now being acknowledged as the gold-standard of public health campaigns, the same tactics are being applied to another deeply culturally embedded practice (as smoking was a generation ago), namely alcohol consumption.

As with smoking, the initial restrictions have been around advertising. Then (rather like the 1970s campaign that smokers should choose cigarettes with filters and leave long stubs) there has been the definition of safe drinking limits, which turn out to have been ‘plucked out of air’. Now, as happened with smoking, some campaigners say that there is no safe limit for alcohol, and although that is not mainstream in the way that it is for smoking it is accepted to be true for pregnant women. Meanwhile, just as there used to be a differentiation of ‘light’ or ‘social’ smokers from the hardcore we have a similar differentiation of social and ‘binge’ drinkers, with a binge drinker being someone drinking more than 3 pints of beer. The key move in anti-smoking discourse was to establish the notion of passive or secondary smoking, and the same shift has been mooted by former UK Chief Medical Officer Sir Liam Donaldson, who is also responsible for the Orwellian declaration of aiming for the complete denormalization of smoking.

So here’s another prediction – as smoking fades away, restrictions on alcohol will increase along with restrictions on sugar and ever more demonization of obesity. Each restriction will give rise to failures which far from being unintended will have been designed to fail, in order to justify further restrictions. But the law of unintended consequences will still hold, and indeed it is already very clear that this is so. Because the more that unhealthy practices, such as smoking, drinking and over-eating are reduced, the more we see the degradations of dementia, of old age blighted by complex and intractable multiple illnesses, of obscure cancers that were rarely known before.

Moreover, since taxes on smoking are, massively, a net contributor to the NHS (and the same is true for alcohol) the less we smoke the more difficult it will be to fund the healthcare for the longer lives we will indubitably – for, of course, the anti-smoking campaigners are quite right to point to its dangers – be living. But that, too, is not really an example of an unintended consequence since, as Jo Brewis and I argued in our article, the real motivation of the anti-smoking movement is not public health, but the imposition of a morality about smoking that long precedes, and proceeds quite independently of, any scientific or medical rationality. They simply reproduce, in modern language, King James I's (1604) Counterblaste to Tobacco:

Have you not reason then to bee ashamed, and to forbeare this filthie noveltie, so basely grounded, so foolishly received and so grossely mistaken in the right use thereof? In your abuse thereof sinning against God, harming your selves both in persons and goods, and raking also thereby the markes and notes of vanitie upon you: by the custome thereof making your selves to be wondered at by all forraine civil Nations, and by all strangers that come among you, to be scorned and contemned. A custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs, and in the blacke stinking fume thereof, neerest resembling the horrible Stigian smoke of the pit that is bottomelesse.

 

Unhealthy management

The British National Health Service (NHS) is one of the largest and most interesting organizations in the world. It is perhaps the key legacy of the post-1945 Labour government, establishing the principle that healthcare is available free at the point of use and on the basis of clinical need. Almost 70 years later, an authoritative report by the Commonwealth Foundation in 2014 identified it as the best overall healthcare system of a range of developed countries (the others were New Zealand, Australia, France, Germany, Norway, Sweden, the Netherlands, Switzerland, Canada and the US), and the best in eight of the eleven criteria of the report, and in the top three for two of the other three criteria. And this was achieved despite having lower spending per head of population and/or as a percentage of GDP than those, and other, countries.

Perhaps as a result, the NHS has always been a target of dislike, even hatred, for neo-liberals because (rather like the BBC) it demonstrates how non-market, collective provision of services can be both more efficient and more equitable than market provision (by contrast, the US system was the worst of those covered by the CF Report). As such, it has for the last thirty years or more been subject to endless reforms to marketise it through actual private provision or internal competition, and to introduce private sector disciplines and management to make it more efficient. Successive governments have insisted that ‘throwing money’ at the NHS is no good – what is needed is this market-accented reform. Yet, despite this, it is constantly depicted as being in crisis, with daily stories of its failure.

The irony is that these stories reflect, precisely, the consequences of the neo-liberal reforms. This week, there are two such stories. One is about the spiralling cost of employing agency nurses and doctors (i.e. not employed by the NHS directly but bought in). The other is the ‘fatcat’ pay and perks of senior managers. It’s true that both these things are problems – but why have they come about?

In the first case, it’s because of the demand for labour market flexibility and the assumed wastefulness of paying the overheads (sick pay, pensions etc) of permanent staff and the government have been warned for some time that their market-focussed policies were causing the problem. In the second case, the roots of the problem go right back to the 1980s when the neo-liberal claim was that to get the ‘best’ managers the public sector had to pay the going private sector rate. So in both cases supposed public sector waste is a direct consequence of the assault on … public sector waste.

These are case studies in the problematic nature of efficiency which I discuss a lot in the book (especially pp 130-131), but in the case of the NHS this has a particular inflection. The efficiency of the NHS, as attested by the study mentioned earlier and others, arises from the fact that the benefits of healthcare are themselves collective. Innoculation is an obvious example: it is effective to the extent that it is widespread across the population, and it will only be widespread across the population if it is not rationed by price but available on clinical grounds. But the same is true even in less obvious cases – for example, the ill-health of an individual employee impacts upon his or her employer and colleagues. And, for that matter, a collective system will always be able to get better prices on drugs than an individualised system, and the costs of medical procedures always fall as they become mass, standardised procedures (think cataracts and hip replacements).

It has become a truism that the costs of healthcare are rising in all developed countries because of ageing populations, the fact that healthcare inflation is higher than general inflation, and the costs of new medical procedures arising from almost daily scientific advances. The only way to address this is, precisely, by throwing money at it. It’s getting more expensive and that expense can’t be met from efficiency savings. It’s a pervasive meme of neo-liberalism to imagine national finances as if they were household finances. Very well, then. Knowing that granddad and grandma are going to be living longer and needing increasingly expensive healthcare you divert resources to that. But we know that this works best (it’s cheaper, and the outcomes are better) when it is done collectively. The US spends 17.7% of GDP on healthcare compared with 9.4% in the UK (2011 figures) but with much worse health outcomes because of its system. Imagine if the UK spent at US levels using the NHS system! It would be a Rolls-Royce health system.

There are two familiar objections to this, both of them fallacious. One is that the NHS entails the rationing of care. That is true, but it is true in all systems. In an insurance-based system such as the US it is done by insurance companies adjudicating on individual cases, whereas in a socialised health system like the UK it is done via expert assessment of the cost-benefit ratio of treatments.

The other objection is that a tax-based system like the NHS is unsustainable because there is only so much tax that people can pay, so what is needed is a mixed private-public system of the sort found in France or Germany. It’s worth noting, though, that those co-payment systems are also under strain. Even more to the point, people don’t miraculously have money to spend on health insurance that they don’t have available for taxes. To see the problems of co-payment systems one only has to look at what has happened to NHS dentistry which has moved to such a model. And let's be clear what this means: it means people pulling out their own teeth without anaesthetic.

The issue, then, remains one of the best mechanism for translating spending into healthcare. In Britain, no politician is really willing to challenge the free at the point of use principle, an interesting illustration of how deeply embedded the collective principle is, despite the neo-liberal decades. Instead they say that so long as the free at point of use principle is retained, it does not matter whether the provider is public or private. In this model, the NHS is simply a commissioner of services. But this neglects the other cornerstone of the NHS: provision on the basis of clinical need. In other words, private providers will only provide services at no charge if it is cost-effective for them to do so, hence they ‘cherry-pick’. There is no way of squaring this circle: collective provision is both cost-effective and equitable because it is collective provision.

British election: the leaders' debate

This is the second of my posts on the British General Election, this time on the televised debate between the party leaders which was held last night. This is only the second time there has been such a debate in the UK, and the format was different to last time. In the 2010 election only the leaders of Conservative, Liberal Democrats and Labour participated. This time, following various political machinations, they were joined by the leaders of the Greens, SNP, UKIP and Plaid Cymru (the Welsh national party). Thus the full cast was Natalie Bennett (Greens), David Cameron (Conservative), Nick Clegg (LibDems), Nigel Farage (UKIP), Ed Miliband (Labour), Nicola Sturgeon (SNP) and Leanne Wood (Plaid Cymru). The debate lasted for two hours and was organized around four questions on the economy, the health service, immigration, and the future for young people.

In many ways it was this format that had the biggest effect. It meant that each leader had relatively little time to speak and when they did it was highly structured. There was little audience participation (I think by instruction from the broadcasters) and it was hard for any of the leaders to really get a sense of audience reaction – there was little applause, no catcalling and just one heckle towards the end. In short, the atmosphere felt quite sterile. Certainly it was difficult for any single leader to dominate proceedings, and none did.

Opinion polls and comments since the debates suggest that no one emerged as a clear ‘winner’or ‘loser’, although Nicola Sturgeon has been the most widely praised. I think this is deserved: she gave a strong, calm and confident performance. One quite likely permutation of the election result is a Labour minority government supported by the SNP and if so that will be an interesting outcome, since Sturgeon is some way to the left of Labour and would be likely to push strongly against austerity economics.

As for the other leaders, David Cameron, who had been resistant to the debates taking place, seemed somewhat ill at ease and disengaged. He can be an accomplished speaker and expectations would have been quite high that he would stand out, so I would think his supporters would be disappointed. Ed Miliband, by contrast, started against low expectations since he is widely seen as lacking charisma. Thus it was relatively easier for him to exceed expectations, so his supporters may be relieved. It would be hard to say that either of these two – the only ones with any expectation of becoming Prime Minister – decisively defeated the other.

Nigel Farage will have had high expectations from this debate. He is often an accomplished and effective speaker, skilled in projecting an image of straight-speaking normality. But his style relies a lot on the use of humour and bombast, and the rigid format and stage-managed audience weren’t a good format for these. He wasn’t able to dominate proceedings as he might have done in a head to head, and it was notable that Cameron and Miliband barely addressed him, treating him as almost an irrelevance. He was also the only one of the leaders who looked physically uncomfortable. His supporters profess themselves pleased but there was no breakthrough moment of the sort they would have hoped for.

Of all the leaders, Natalie Bennett started with the lowest expectations given recent painful media performances (which I discussed in another post). To exceed them all she really had to do was not implode, and she easily exceeded that bar. Leanne Wood was probably the least known of the politicians to a national audience and gave an assured performance, albeit one which (not unreasonably) mainlined on Welsh rather than national issues. Sturgeon, by contrast, had tended to emphasise the role SNP MPs could play in Westminster politics. But it was Wood who garnered one of the few rounds of applause of the night, in a sharp put down of Farage’s claim about immigrants using the health service.

Nick Clegg’s performance in the debate has been less commented on in the media than that of the other leaders. It was actually quite punchy and fluent. But whereas at the last election debate his was the runaway success, attracting by far the most praise and interest, the context has now changed and he has neither the edge of being a newcomer challenging the political establishment nor the significance that attaches to the prospective Prime Ministers.

Overall, we didn’t learn very much that was new, and it seems unlikely to me that many viewers will have changed their voting intentions on the basis of the debates. Nevertheless, it was a fascinating evening and, again, this was because of the format. Firstly, there was a far wider range of views represented than has been normal in British politics, and with each leader being given the same amount of air time these views were represented as all having equal weight. That felt like a refreshing change following an era which, as I wrote in my last post, has been dominated by the shared neo-liberal orthodoxy of Conservative and Labour parties. Secondly, the dynamics of the debate felt changed by the presence of three women – who, relatedly, each represented ideologies at odds with neo-liberalism. Since Margaret Thatcher’s departure, British politics has been heavily dominated by white men in suits and suddenly that domination has evaporated (as regards the men, but not the white bit). It was Thatcher who coined the phrase ‘there is no alternative’ (to free markets), otherwise known as Tina. But Tina, for one night anyway, was banished by Leanne, Natalie and Nicola.

Beef with efficiency

The current horsemeat in frozen beef meals scandal is an interesting illustration of the issues around what constitutes efficiency which I discuss at several points in the book. The story reflects many different dimensions of this. The way that a hugely complex globalized supply chain has developed reflects one particular, dominant, understanding of organizational efficiency: driving down costs by all means possible. That presents some serious problems even leaving aside the use of horsemeat, such as the unappetising use of mechanically recovered meat products. Thus, even if our microwaveable lasagne only contained beef, we might be rather horrified to see just what that really consisted of, as this selection of charming images allows us to do. But this is what ‘efficient’ use of carcasses means in the dominant understanding. Passing off horsemeat as beef, of course, represents something beyond this ‘normal’ efficiency, because it involves fraud and misrepresentation. But it is only the extension of the same logic. For the suppliers and producers involved it is, precisely, efficient.

To prevent such frauds, and to control the adulteration of foodstuffs in general, requires state regulation, and such regulation is one of the earliest examples of regulation of the free market. This becomes much more complex in extended global supply chains which span national jurisdictions, another of the ways that politics has not caught up with economics as I said in an earlier post about tax avoidance. But it also makes it bizarre that, in the UK, recent years have seen a reduction of food inspectors. Of course this, too, is ‘efficient’ with respect to government budgets, ‘removing the burden of red tape’ from businesses, and ‘getting value for money’ for the taxpayer. In other ways it is grossly inefficient. For a little more paid in tax, the supermarkets and food brands now suffering a catastrophic collapse of confidence in their products - and maze of expensive legal actions - could have had an ‘efficient’ system of inspection.

Then, beyond this, there is you and me, the consumer. Unwilling to spend our time buying ingredients and cooking them, we find it more efficient to buy packaged up meals for the microwave. Worldwide, consumption of ready meals increased by about 10% in volume 2010-2011. And not only do we want it quick, we want it cheap. Efficient? Perhaps not, considering the very high amounts of salt and fat that some of these meals contain. So maybe the time we saved on cooking will turn out to be dwarfed by the time we end up spending in hospital. There will be plenty of time on the cardiac ward to ponder the meaning of efficiency.