Our newly published report reveals that 1 in 5 Integrated Care Boards (ICBs) in England are ignoring both NICE guidelines and government advice by rationing joint replacement surgeries based on a person’s body mass index (BMI) alone. The guidelines state that people should not be barred from joint replacement surgery exclusively because of overweight or obesity based on body measures such as BMI.

Using BMI as a single threshold fails to reflect a patient’s overall health, circumstances or need, preventing them access to treatment altogether. Instead, decisions about surgery should be made through shared decision making. 

People waiting for joint replacement surgery, often due to arthritis, have already spent many months or years with their health and mobility in decline , as joint replacement surgery is the final line of treatment. Joints in need of replacement are incredibly painful and severely impact the ability of individuals to exercise , which can lead to weight gain. It is counterproductive to deny surgery that could get people back on the road to mobility and improved health and fitness. 

ICBs such as Black Country, Sussex, Herefordshire and Worcestershire, among others, have adopted rationing-based policies, often justifying them by pointing to the increased risks associated with a higher BMI. However, research surrounding this is mixed, and multiple large-scale studies shed light on the significant benefits of having the surgery, which outweigh any risks.  

BMI alone should not determine who can access planned orthopaedic surgery, nor should anyone be denied its benefits. Yet inconsistent policies across the country mean patients’ access to treatment too often depends on their postcode.  

For example, a patient with a BMI above 35 will be denied surgery with Lincolnshire ICB but may qualify for surgery at Leicester, Leicestershire and Rutland ICB, where their cut-off point is a BMI above 45. In practical terms, a difference of about 13kg can determine whether someone receives life-changing treatment or is left in pain.   

As the NHS enters a pivotal period of reform, with ICBs clustering and merging from April, there is a rare opportunity to review and reform local policies. Newly formed systems must seize this moment to end practices that unfairly penalise patients and restrict access to surgery based on where they live.  

For people with arthritis, time spent waiting is time spent in pain. Delays can result in prolonged pain and further deterioration of the joint, which could be prevented earlier through surgery. These are not neutral delays; they are periods of avoidable suffering.  

Being denied [a] knee operation for being overweight only made things worse because of problems getting around, so you end up putting on even more weight

(Man, aged 55+)

The pain can affect people’s abilities to carry out daily activities. Arthritis UK’s Left Waiting, Left Behind survey found that 68 per cent of respondents said that waiting for treatment had impacted their ability to work, and 73 per cent said that it had impacted their social activities. No one with arthritis should be forced to give up the daily activities that give life meaning because of arbitrary eligibility thresholds.  

Moreover, being out of work or on sick leave can cause significant emotional and financial distress, taking a toll on an individual’s mental health. 66 per cent of respondents said that waiting for treatment impacted their mental health. Therefore, this highlights how a single decision can trigger a cascade of harm.   

While some patients can skip the agony of long waits through private weight loss injections or surgery, these options are only available to those with the means to pay, creating a two-tiered health system. Healthcare should not depend on wealth, and access to treatment should be equal.  

I have felt a little isolated. Financial impact  – not being eligible for financial support. Weight gain due to physical limitations.

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(Female, aged 55+) 

The most affected are people living with arthritis in deprived areas, where obesity rates are higher and the risk of knee osteoarthritis is around 50 per cent greater. Yet these communities often have limited access to the required weight management services and, as a result, are disproportionately affected, further entrenching existing health inequalities. We are deeply concerned that these policies continue to penalise those already most vulnerable.  

No one should be excluded from accessing surgery that could greatly impact their lives because of an arbitrary metric. Such policies do not just delay treatment; they institutionalise injustice and widen inequalities. 

As the UK’s leading arthritis charity, we are concerned that ICBs are implementing BMI policies in a bid to cut waiting lists and running costs through rationing. We want to ensure that patients come first and stand firmly against any cost-cutting policy that inappropriately rations surgery based on BMI rather than clinical need.   

We are in the process of contacting all ICBs named in the report with its findings and hope to see the cessation of BMI policies to restrict access to surgery. We are also calling for the end of these practices and for ensuring fair, timely access to surgery for everyone who needs it.   

It was a Labour MP who first used the phrase to me: the Miliverse. He was worrying, before PMQs, about a world where Ed Miliband gets a promotion to Downing Street – either as Chancellor or, even, as Prime Minister.

If he was worried then, he’ll have been even more worried after PMQs. Because yesterday, in the House of Commons chamber, Sir Keir Starmer seemed not just comfortable with the idea that he is a member of Miliband’s government – he was almost eager to admit it.

Under questioning from Kemi Badenoch over the decision not to issue new licences for North Sea oil and gas drilling, Starmer slipped into full legal mode. He was at pains to clarify that the decision over the Jackdaw and Rosebank oilfields rested not with him but with the Secretary of State for Energy. Legally, it was Miliband’s call. Badenoch pounced. “He is the Prime Minister!” she told the chamber, deriding Starmer’s retreat into proceduralism.

The Prime Minister was, in effect, publicly conceding what one shadow cabinet minister put to me: that Miliband is “the real prime minister”. Another shadow cabinet minister joked: “It isn’t something we didn’t already know.”

But it is worth pausing on what that actually tells us about Starmer, because the Miliband story is, at its core, a Starmer story. Miliband’s influence over this government is not merely a function of his own ideological energy, though that is clearly considerable. It is also a function of the vacuum at the very top.

This is the context in which Miliband has thrived. When the man at the top is reluctant to own his government’s most politically contentious decisions – whether that’s the North Sea, net zero, or the broader direction of economic policy – someone else will own them instead. His Labour manifesto read: “We will not issue new licences to explore new fields because they will not take a penny off bills, cannot make us energy secure, and will only accelerate the worsening climate crisis.” That is clearly what they truly believe, so why won’t Starmer say it rather than hide behind legal process? Miliband is happily continuing the message of the manifesto, and filling the vacuum at the top while doing it.

As I have written before, Miliband’s influence on this Labour government has been perfectly clear: “The push towards ever more stringent net-zero obligations continues apace, even when the immediate effect is to increase costs for British taxpayers and businesses.” The Spectator’s Tim Shipman even reported that it was Miliband who commanded the majority around the National Security Council table on any involvement in Iran, with Starmer taking direction rather than giving it.

In a profile with the New Statesman, Miliband himself was candid about the scope of what he is trying to achieve. “We are charting a course to a different economic settlement,” he said. “I talked about it as leader and didn’t get to implement it.” He is implementing it now.

And there is the question of what comes next. Nigel Farage, of all people, has reportedly told friends he expects Miliband to be Prime Minister by 2027. That prediction may flatter his instinct for provocation, but it is not entirely absurd with Starmer’s leadership on the rocks.

Yesterday, the Prime Minister yet again tried to protect himself by hiding behind Miliband, but only revealed more about his lack of leadership in the process. 

The Labour MP fretting in the corridors before PMQs, I suspect, finds that prospect deeply worrying – Ed Miliband’s world is not one he wants to inhabit. But without any voters say, the Miliverse seems to be ever expanding.

John Oxley is a consultant, writer, and broadcaster. His SubStack is Joxley Writes.

Few in the Conservative Party will be relishing the thought of the local elections. With just over a month to go, our prospects in the contests look bleak. The party has never gone into a set of locals with such a poor national polling position. The rise of Reform also means we are likely to face challenges in areas where we were previously strong. Though the electoral geography this time leaves Labour more exposed overall, few positives are likely to come from the night.  

When talking about these shifts, we tend to focus on the shockwaves the results will send through Westminster. Commentators question how much jitteriness it will impart on MPs who see their local council fall away. Whether it will tempt more into defections or trigger another round of party regicide. But there is another question, less dramatic, more fundamental, that these elections ought to prompt – about what Conservatives are here to offer at the local level.  

Defeat in the 2024 election required an examination of where the party stands and how it relates to the challenges and voters in the current national political landscape. Our subsequent challenges in local politics should prompt the same sort of thinking about how we wield power where it most directly touches voters.  When it comes to delivering services, fostering communities, and making a difference that people see, the question is not just about how the party wins back power, but what it does with it.  

Localism, after all, should be close to the heart of the Conservative Party. Our suspicion of big government ought to incline us toward placing power in the hands of those who understand their areas best, the people who actually live in them. We should celebrate a government that is local, accessible, and human in scale. And local institutions should be central to any serious conservative vision of how the country works, the little platoons of boroughs and counties, trusted to know their ground, doing what distant Whitehall cannot. 

The reality of local government in 2026 makes that vision harder to sustain than it should be. The decades-long failure to address social care has left most councils unable to do much else. Local authorities are crushed under the burden of these obligations and funding shortfalls.  Even the most prudently run councils are struggling, and many are close to insolvency. Everything else that councils do, the small civic institutions that give communities their texture, seems unsustainable.  

This is a particular problem for the right. The traditional offering of local Conservatives has been fiscal prudence – less spending, and lower bills. That has now been pushed to the limit. Many of our councils have done well in adapting to constrained times and have found new efficiencies and savings they can pass on to the taxpayer. Now there is little fat to trim. Even Reform councils that replaced us have been forced to admit this, arriving with grand plans of cutting waste and instead colliding with fiscal reality.  

The other canard of local government campaigning, opposing development, has also now come to haunt the party. The instinct and the electoral calculus behind blocking housing were understandable, but their cumulative effects have exacerbated a national crisis. The shortage of homes falls hardest on the young, and in courting the settled, propertied voter, local conservatism has too often had little to say to anyone else. There is a deeper irony too: in resisting development, councils have sometimes prevented the very renewal that would keep their communities vibrant.  

These pressures have arrived alongside new political challenges rather than in spite of them. Reform has taken the most seats, but the Lib Dems and Greens have made gains too, in very different kinds of places, for very different reasons. The breadth of that squeeze suggests something more than a temporary unpopularity. The same offer, made in the same way, is unlikely to be enough, whether the goal is to win back councils or to give conservative local government a renewed sense of purpose. 

The Conservatives need a proper vision of what modern local governance looks and feels like. This should go beyond simply keeping council tax rates down and NIMBYism. Fiscal prudence is part of it, as is responsible development. But it should also be about delivering effective and responsive services, facilitating cohesive communities, civic trust and stewardship. In short, pushing towards councils that are truly Tory.  

This also requires a better conception of the relations between local and central government. When in power in Westminster, Tories have tended to be jealous guardians of power. We’ve favoured centralisation, lest loony Labour councils run away with it. Ultimately, we should be more comfortable with this risk, letting local voters decide who to trust. Equally, we should engage seriously with Rachel Reeves’ plans for greater fiscal devolution. Incentivising local authorities by allowing them to keep more of the proceeds of growth changes the dynamics of development, giving communities a clearer path to share in the upside as well as the costs.  

The local election results will captivate Westminster for a few days, but whoever wins may wield power for years. The actual business of governing our localities is forgotten, as are its challenges and impacts. For associations facing elections, the next six weeks will be a hard slog, and many of the results will be disappointing. But they may also offer an opportunity for renewal, re-examining what the Conservatives offer, and making our case in more volatile electoral politics. The night itself matters less than what the party does with it, and whether it advances our understanding of what Conservative local governance can offer.  

While this election season may be bruising, there is, nonetheless, reason for optimism. Reform’s polling is declining, and where they have won local power, they have proven unimpressive. Their gains last year have been dogged by scandal, infighting, and failure to deliver on many of their proposals. The insurgent offer is already looking tarnished, and the Conservatives can maintain their position as the serious party of the right. That creates a genuine opportunity, but only for a party that has done the harder thinking about what it believes, what it will build, and what kind of local government it wants to be trusted with.  

The Conservatives have a long and proud history in local government. It should be central to what drives us: the Toryism of local communities and networks, of prudent stewardship and genuine civic belonging. That tradition is worth recovering, not merely because it wins votes, but because it reflects something true about what the party is for. It also means regaining our sense of how, at all levels, we use politics to make things better. The local elections will come and go. The question of what conservatism is for, in the places where people live, will remain. It deserves a serious answer.

Terri Bloore is the Conservative candidate for Mayor of Newham.

When Mark Carney took to the stage at the World Economic Forum Annual Meeting 2026 in Davos less than two months ago there was deft silence followed by rapturous applaud. European’s and democrats saw his speech as somewhat anti-American. That conclusion says more about the current geopolitical mood than about what he said.

I was in attendance, wearing that odd combination of snow boots and a suit, and felt the atmosphere change, but in my view Carney’s message was not about turning away from the United States. It was about recognising that the world has changed and that countries in Europe and beyond must adapt accordingly.

With President Trump in attendance the American turnout was indeed palpable.  Yes ‘America House’ and its huge eagles dominated the promenade, yes there were robots walking streets and men dressed as polar bears – larger than life and a little more brash than years before. But the atmosphere was not anti-American.

In less than two months, the world has shifted dramatically.  The central theme of Carney’s speech was that a world order built on open trade, relatively stable institutions and strong American leadership is under strain and one we cannot take for granted. Since that speech, a lot has happened, not least the conflict in the Middle East. Looking back, it seems as though Carney was preparing us for this twists and turns that we are facing as soon as we turn on the news.

Economic policy, he argued, is increasingly becoming geopolitical policy. Supply chains, energy markets and trade are now instruments of power. For decades, many Western countries operated under the assumption that rules-based institutions and global economic integration would naturally reinforce stability. That assumption is now far less certain.

Carney’s argument was that countries such as Canada, the UK and many European nations can no longer simply rely on the system working as it once did. They must strengthen their resilience and work more closely with one another to protect shared values and economic stability.

None of this is particularly controversial in private discussions among policymakers. In Davos this year, it was practically the backdrop to every panel conversation. Yet the moment Carney suggested that middle powers needed to assert themselves more clearly, some observers interpreted it as a critique of the United States.

In today’s political climate, almost any conversation about strategic autonomy is quickly framed as a rejection of Washington. But that is not what Carney was arguing. Standing in Davos, the message sounded less like a rebuke and more like a pragmatic assessment of geopolitical reality. The world is becoming more fragmented. Economic competition between major powers is intensifying. Alliances must adjust.

The idea that Europe should have greater strategic confidence is not anti-American. In many ways it strengthens the Western alliance by making partners more capable and resilient. If Carney’s speech had truly been a rejection of American leadership, his subsequent positions would look very different.

Instead, when tensions escalated in the Middle East and the United States moved against Iran, Canada signalled its support for the broader security objectives shared by Western allies. That decision alone undermines the narrative that Carney was advocating a break from the United States. It demonstrated what most policymakers already understand: Western security and economic stability still depend heavily on cooperation between North America and Europe. The alliance may be evolving, but it has not disappeared.

What struck me most in Davos was not the speech itself but the reaction to it. In a world increasingly shaped by geopolitical rivalry, even moderate calls for strategic realism are quickly interpreted through a binary lens.

Pro-America or anti-America. Alignment or independence. Carney’s argument was more nuanced than that. The world is entering a period where the assumptions that once underpinned globalisation are weakening. Institutions are under pressure. Economic relationships are becoming more politicised. Strategic competition between major powers is intensifying. In that environment, middle powers cannot simply assume stability will hold. They must invest in their own economic resilience, cooperate more closely with partners and be prepared to defend the values that underpin open societies.

In many ways, the speech reflected the quiet consensus I saw across Davos this year.

The transatlantic alliance remains fundamental. But the world it operates in is becoming more volatile and more competitive. Recognising that reality is not a rejection of the United States. It is an acknowledgement that maintaining Western values in the twenty-first century will require stronger partnerships, greater resilience and a more honest understanding of power.

Elliott Malik is the Nature Programme Officer of the Conservative Environment Network and the Director of the Conservative Friends of CANZUK.

Britain is one of the most nature-depleted countries in the world. Unfortunately, regulations designed to protect the environment are not only failing to restore nature but are also suffocating developers with needlessly complex red tape. This is the worst of both worlds.

That is why the Conservative Environment Network has launched ‘In Pursuit of Harmony’, which offers bold new ideas to streamline red tape, harness private investment, and give Britain new homes and more nature.

The most important proposal in our paper is our common sense approach to Biodiversity Net Gain (BNG). For those unfamiliar with BNG, it was introduced by the last Conservative government. It requires almost all new housing projects to improve biodiversity, either within the development (known as ‘on-site’) or by participating in a natural capital market. Developers can access this market to purchase BNG credits from landowners to restore nature elsewhere (known as ‘off-site’).

This concept of BNG is important for several reasons. Off-site BNG credits could lead to a £3 billion boost for farmers and rural communities, as farmers turn poor agricultural land into havens for nature and sell this uplift to developers. It could transform soulless developments into real homes and communities, bringing pride back to communities and encouraging people to put down roots. Perhaps most importantly, it can help fulfil our conservative duty to protect our natural inheritance. This will allow us to once again take pride in the natural world which past generations have left for us, and restore it for the generations after us to enjoy.

Although the concept of BNG is sound, the system we have today has become bloated and unwieldy, with disparate requirements shoehorned into it.

Notably, on-site BNG – which can be difficult to achieve – has been prioritised at the expense of off-site. It was hoped that if housebuilders promised more local amenities, this could make planning applications more likely to succeed. The government then forced developers to create a higher BNG uplift in off-site restoration projects, effectively penalising those who want to purchase credits to improve biodiversity elsewhere.

These political choices hamstrung BNG from the outset.

By disincentivising developers from creating nature off-site, we created an inflexible system for housebuilders whilst stifling the benefits for landowners, farmers, and our economy. It has also made developing smaller plots of land considerably more complicated and expensive because developers – mainly SMEs – must either overcome the difficulty of improving biodiversity in small areas or purchase very expensive credits elsewhere. This is a tragedy, both for housebuilding and for nature restoration.

BNG has clear problems, but its potential remains compelling. The solution is just as straightforward as BNG should be, which is why CEN is proposing to make BNG fit for purpose by getting rid of the distinction between off-site and on-site BNG. This will return BNG to what it was initially intended to be: a flexible, nature restoring policy which adds to our economy. If we want to build more houses, we must not penalise developers for choosing to improve the natural environment off-site.

As more developers choose to purchase credits, the BNG natural capital market will blossom, creating an important new revenue stream for farmers and landowners who can turn unusable areas of land into new habitats.

Reforming BNG is vitally important, but we can go further. Needless red tape makes it incredibly burdensome to bring nature to new communities. We should be weaving nature into our communities to improve our environment, make our communities more beautiful, and to create pride in place. Some of these changes are simple, such as extending permitted development rights to ponds, and freeing businesses to install façade gardens.

We also recommend that our land use becomes more efficient and housing more attractive, through ‘gentle densification’. This is important because we want the homes of the future to be places people can be proud to live in, and from which new communities can form.

This paper recommends targeted and profoundly conservative reforms. If we liberate developers from unnecessary regulations, we can unleash the power of free markets: restoring nature, providing new income to farmers, and building many more houses. It is possible to achieve the twin goals of building the houses we need and restoring nature. We know what to do; now we must pursue harmony between our built and natural environments.