Competition and the NHS – reponse to Le Grand

Today on the LSE policy and politics blog, Julian Le Grand has posted a piece that is critical of our earlier blog casting doubt on the LSE team’s work claiming ‘competition saves lives’. You can read it here (http://blogs.lse.ac.uk/politicsandpolicy/2012/03/09/hospital-competition-le-grand/).

I’ve posted my reply on the LSE website, but here it is again for completeness’ sake.

I have liked and admired Julian Le Grand’s work for years, and he is on many my teaching reading lists. But I do have to wonder what is going on here.

There is a basic category error in the piece above – competition doesn’t save lives. It never can. Clinical workers save lives, hopefully with the support of managers. To simply assert (as economists are inclined to do) that competition changes incentives is to not engage with the difficult, messy, empirical work of exploring exactly what has changed and how (if anything, and the moral of reorganisation in the NHS is how little changes). So the key question here is what exactly changed after 2006, and how did it change both managerial and clinical behaviour. The answer, I’m afraid, is that we really don’t know.

Even reviews of research that consider the econometric work that Cooper and Propper favour on their own terms find there are big gaps (for example, Bevan and Skellern in the BMJ (http://www.bmj.com/content/343/bmj.d6470). Most particularly, their research is based on a ‘black box’ where incentives and changes are assumed rather than being empirically demonstrated.

It is also interesting that Le Grand cites the King Fund’s work as supporting his claims. Again, that is very contestable, as David Hunter’s review of the book, again from the BMJ (http://www.bmj.com/content/343/bmj.d7786) suggests. My reading of the book was that Labour’s market-based improvements were extremely modest when compared to what was achieved elsewhere. It therefore seems odd that Le Grand presents this work as supporting him, when I’m really not sure that’s what the book is saying.

Above all, it seems to me that it’s time we started being a bit more humble about our work. Le Grand and Cooper, in their FT piece, seemed to be suggesting that there is only one way to do research, and people who do other kinds of work are mere ‘intuitionists’. This reads to many of us as an intolerant and rather blinkered view of social research. In order to understand what is going on in the NHS we need a range of different methods and different types of work. To imagine we can provide some kind of definitive answer, as they appear to be suggesting, from work that doesn’t empirically examine whether the changes they believe are going on are actually happening, without actually asking anyone involved in their implementation, seems a little odd.

Conflicts of interest and the NHS bill

Let’s assume for a moment that the NHS bill passes, and that it leads, as the government want it to, to a competitive environment for care. Every thought how much conflict of interest this would lead to?

Let me say, first of all, that I like doctors, and what follows isn’t meant to be hostile, even if it reads a such.

GPs are the cornerstone of the reforms. They are meant to be getting involved in commissioning as well as acting to make sure patients make the best choices (at least they will be advising patients on choice, at most making the choices for patients if, like me, they don’t think they are qualified to be making choices).

Thing is,  most GPs have been asked to consider themselves as independent contractors in the NHS. They get paid on a really complex mix of different kinds of fees, and have increasingly invested in provision in areas of primary care outside of their own surgeries (which they may also part-own as well). If you are regarding yourself as an independent contractor in a non-competitive environment all this is at least moderately sensible (I’d prefer GPs to be salaried myself, buy hey ho).

None of these arrangements, however, are sensible in a market-based environment. Somehow we are going to have to make sure GP commissioners don’t face the situation where they have to choose between providers, some of which they have a financial interest in. That will mean potentially excluding the very large numbers of GPs who have done largely what the government asked them to, and got involved in local healthcare provision, and even then GP commissioners don’t have interests themselves, they will be in a difficult position because of their partners’ and colleagues’ financial interests. Even in advising patients about choices, GPs will have to disclose their financial interests – and what on earth are patients meant to do with this information? If you are in a collaborative environment, not driven by profit, there is greater scope for allowing GPs to refer to organizations in which they have an interest, as this is surely covered by professional ethics. If, however, we are moving to a competitive, for-profit basis, things are getting a lot more fraught. I’m not convinced the government has worked this through.

If the situation for GPs is going to get a lot more complex for hospital consultants. Consultants may work for both the NHS and private sector. In that case, they will be effectively working for organizations that are now expected to compete with one another. Surely that can’t be right? It would be like someone working for both Apple and Microsoft – far too much potential for conflict of interest through seeing information that is commercially confidential. In a competitive environment, I’m afraid, you have to choose whose side you are on, and stick to it. Professional ethics, again, don’t cover this.

Professionalism, as US sociologist Elliot Friedson suggested is a third logic – neither market, nor bureaucracy, but something else. If healthcare is going to be delivered competitively, you can’t depend on professionalism alone to prevent conflict of interest. And if you are depending on professionalism to prevent a creep of non-professional, market-based ethics into relationships, why introduce markets?

There is one more conflict of interest that has sadly become very apparent in recent weeks. Every time the NHS bill has been debated in the Lords, a running commentary on twitter has appeared explaining the financial interest many of those speaking have in relation to private medicine. That hasn’t stopped them, however, from making points entirely in favour of that interest. That is breath-taking – and to think that politicians wonder why we no longer trust them. If we can’t depend on politicians to deal with pretty obvious conflicts of interest, I wonder what the future holds for those that are tasked with implementing their reforms.

Just because I oppose the NHS bill, it doesn’t make me a lefty.

As I write this it seems like the default attack on those who oppose the NHS bill is that we are trying to undermine the coalition government, and that we are, as a consequence, lefties.

Well, it’s good to see that government continue not to allow evidence to get in the way of their arguments.

Other can make their own arguments. I spent most of the 2000s arguing that Labour’s approach to the NHS was wrong – I was pleased additional funding had at last appeared, but depressed that they thought that, as the decade wore on, trying to create some kind of marketplace was the answer. I wrote at least an article a year on this and so hope to be able to show at least some kind of track record here.

Now I’m criticising the coalition government for making the same mistake. I think both Labour and the coalition are wrong – this direction for health reorganisation is a mistake.

Ah (the coalition, or perhaps Alan Milburn might say) – the reason you don’t like either Labour or coalition health policy is that you are a proper lefty – you don’t believe in markets, and you want the government to control everything.

Er. No.

The reason why I don’t believe markets work in healthcare is that I like my markets to be competitive.

For markets to work, there has to be competition. Those working in competitive environments have to fear consumers going elsewhere, with the potential loss of income being important.  Those in charge need to be able to change what’s going on in their organizations to prevent their customers going elsewhere. But in the NHS as comprehensive providers of care can’t and won’t be allowed to go bust. Equally I’m not clear exactly what health managers can do to prevent patients choosing to go elsewhere. That’s down to clinicians. Clinicians are generally in short-supply, and so suggesting they are threatened by patient choice seems odd. Without competition, markets are pointless.

Equally, offering patients choice does not mean you have made a market. Offering me a choice between two local hospitals doesn’t mean they are in a competitive relationship. There might be enough patients for them both (that’s why we have waiting lists). A few might change from the referral their doctor might have given them at the margins, but that’s hard signals the outbreak of competition. Even if there were some benchmark that allowed patients to choose the ‘best’ hospital, we couldn’t allow every patient to choose it as that would drive up waiting lists and put the other one out of business. And we can’t allow comprehensive providers of care to go bust – we don’t have the capacity to survive without them. Patient choice is not the same as competition.

The reason why market don’t work in healthcare is that there isn’t enough competition, patients lack the information to be able to choose, patients may not actually want to make choices (surveys tell us they would prefer their local healthcare organizations simply to be good), and there is little incentive for comprehensive hospital providers to improve through competitive forces as they can’t be allowed to go bust.

Where we introduce market mechanisms where they cannot work, all we get is abuse. We give healthcare managers big pay rises to pretend they are running competitive business enterprises when they are not, but ask them largely to do the same job as before. We end up bailing out hospitals when they run out of money (as, for example, with the £1.5bn PFI bailout). We give private providers access to public money to the point where they depend upon it for 25% of their revenues but still pretend to be dynamic, independent companies. What nonsense.

Above all, all this nonsense distracts us from the serious business of marking healthcare better. How much money do we have to waste on the purchaser-provider split before we consider whether any real benefits are accruing from it? How much extra healthcare could we have bought with all the money poured away on pointless reorganizations since the 1980s? Making healthcare better involves time and effort and evidence. Imagining you can reorganize for it is nonsense.

Both Labour and Conservative politicians who have spent billions on trying to force markets upon healthcare should hang their heads in shame. You don’t need to be a lefty to see that markets don’t work in healthcare. Taking a couple of basic courses in economics, sociology, politics and the history of healthcare should do the job.

Evidence, fact and opinion in the NHS bill debate

On 23^rd February on the Daily Politics, Clare Gerada (CG) appeared with Anna Soubry  (AS) to debate the NHS bill. I’ve included a rough transcript at the bottom of this piece to try and show what happened, along with a link to a recording of the debate on the BBC website. I think, for me, it exemplifies what has gone on during the NHS bill debate.

The debate begins with CG explaining how she has consulted with her GP colleagues, and how her views can be claimed to be representative of them. She says some parts of the bill are good, but the results of the RCGP consultation suggest that her members don’t want it.

Andrew Neill (AN) then tells AS that CG represents 90% of GPs, AS replies ‘I think she’s wrong’. AS explains that CG is wrong because she has spoken to ‘Real GPs, on the ground’ in her constituency, that consortia were formed there before the government were even elected, and that she was approached by a GP from her constituency (who doesn’t practice there) who told her that she had to get the bill through so he could, in his words, ‘deliver the treatment to my patients that I want do do’.

AN then challenges what AS is saying, saying it is ‘anecdotal evidence’,.

AS replies ‘It may well be’.

AN challenges AS to explain why her evidence is more important than CGs. AS replies she didn’t say it was.

After a period when everyone tries to pick the discussion again, CG explains that her own practice was one of the commissioning pathfinders, and suggests perhaps the GP AS spoke to was one of the 56 out of 2,500 who voted….but is cut off by AS who asks ‘What about the doctors in my constituency….what about the 95% of other areas of the country?’

CG suggests that AS’s views are not reflected in what she is hearing from 18 months of consultations.

AS replies ‘We’ve consulted as well’.

AN then suggests that CG has a ‘strong ideological opposition to competition or further choice’. CG asserts that the bill is ‘an attempt to privatise the NHS’ (AS then engages in much shaking of her head), and that there is nothing in the bill to prevent a mixed-funding system (as per the US) appearing.

AS then asserts that is ‘an opinion. That is not a substantial fact…’

CG then replies that the RCGPs are not against competition, but against ‘the full, fettered, any qualified provider where you have everybody competing for the same hip, the same knee’.

The debate then ends.

What his shows for me is the two very different styles of argumentation and evidence presentation that we have seen during the bill.

CG is attempting to use first, the argument that the RCGPs have consulted widely during the bill, and so she knows the opinions of the 90% of GPs she represents. This argument is based on legitimacy through repeated consultations. Legitimacy through democracy.

AS attempts to refute this by claiming that the GPs she speaks to in her constituency say differently, and one GP in particular has urged her to press ahead with the reforms. She admits this may well be anecdotal.  She then gets herself into a tangle when AN asks her why we should view this anecdote as being more important than CGs consultations, to which AS replies ‘I didn’t say it was’. This leaves us wondering why she mentioned it in the first place.

The argument for the NHS bill has often been outright anecdote, or anecdote dressed as science. Outright anecdote is the position adopted by AS here, as well as by David Cameron in PMQs where he has repeatedly claimed the medical profession back his reforms because he has spoken to a particular doctor or small doctor group that supports him.

The strategy of using anecdotes as evidence is one increasingly used in British politics. Remember the last election, during the debates, when all the leaders had spoken to someone in their constituency who had told them (something that supported their view)? It is almost as if politicians only believe there is a problem if they’ve heard it themselves from one real-life person (not sure there is another kind), but also that this is the only kind of evidence that actually counts.

In the second burst of exchanges we see another NHS bill argumentative strategy – claiming something is, or isn’t fact. AS claims that CG’s view that there is nothing in the bill that prevents a US-style mixed-funding system is ‘your opinion. That is not a substantial fact….’

Now from someone who has just presented anecdote as evidence, this is an odd strategy to take. Having confused anecdote with evidence, AS is now saying that CGs view of the bill is just an opinion (or perhaps, an anecdote?). 

What is odd is the mixing up of anecdote and fact from AS, but also the way the government more generally have presented anecdote dressed as science on repeated occasions. During the debate, the government has repeatedly attempted to present claims about the need for reform as being based on scientific fact, but which appear to disintegrate upon any scrutiny. Chris Mason’s blog on government leaflets explaining issued after the listening exercise show this clearly (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html).

This approach – anecdote pretending to be evidence – is perhaps even more bizarre than presenting anecdotes and expecting to be believed.

What this highlights above all perhaps, is that the government don’t appear to be interested in any kind of informed discussion about the bill. This isn’t about making the NHS better, or about what doctors think, but about putting in place change no matter what. That is deeply depressing – we deserve higher standards of political debate than they have given us, and a great deal more honesty too.

 

Gerada and Soubry transcription from Daily Politics, 23^rd February 2012

http://www.bbc.co.uk/news/uk-politics-17144005

AN: Anna Soubry’s boss, Simon Burns, he claims that you don’t represent the views of GPs up and down the country in these health reforms, what do you say to that?

CG:  I think I do. I represent 44,000 general practitioners, of which over 90% when we’ve surveyed them very recently wanted me to ask for withdrawal of the bill and that’s against a background of one and half years of consultation. Three surveys, five counsels, five executive councils, a national conference. Endless consultations. I can categorically tell you my members, the members of the Royal Colleges of GPs, do not want this bill. Some of the parts of the bill are good. I mean putting GPs on control of money, putting patients first, addressing health inequalities. But in its totality, the bill is a mess, the bill is flawed, and the bill will not achieve what you and Andrew Lansley and the Prime Minister are setting it out to achieve, and the more Colleges…

AN: We haven’t got too much time. She represents 90% of GPs .

AS: I think she’s wrong.

AN: (Interjection)

AS: No hang on, let me finish. 

AN and AS talk over one other

AN: You said your views represent…

AS: I didn’t say that. Andrew you asked me a question. I didn’t say that. But let me tell you what I think.

AS: I go into my constituency. I talk to GPs. Real GPs, on the ground. In my area, the consortia was formed before we got elected into government they were in existence. They are putting into operation already what we are seeking to achieve

CG: Why..

AS: Let me finish, I don’t wish to be rude. But let me finish and explain. That is my experience in my constituency with my GPs, and let me tell you this. I was approached by a doctor who lives in my constituency but practices in Nottingham. And he took hold of me and he said ‘For God sakes get this bill through, so I can deliver the treatment to my patients that I want to do’

AN: But that’s anecdotal evidence

AS: it may well be

AN: Her evidence is surveys and conferences and..

AS: yeah, but I’m talking about

AN: Why would your anecdotal evidence be more important than hers?

AS: I didn’t say it was

CG: I would as a general practice, we were one of the first waves of

AS: Part time

CG: We were one of the first pathfinders. We have lots of practices across London. I speak to general practitioners. The doctor you spoke to might be one of the 56 that voted, the 56 out of two and a half thousand

AS: What about the doctors in my constituency, that have formed a consortia, that are doing it. What about the 95% of other areas of the country

CG: But that’s not being reflected in what we are hearing in the Royal College of GPs. I’m not a politician, I’m head of GPs. All I’m doing is reflecting the views, and we have consulted over the last 18 months. GPs write to me every day

AS: We’ve consulted as well

AN: Let’s bring..back in. You say your are not a politician. Reading your case against the bill and so on  you do have a strong ideological opposition to competition or further choice

AS nodding

AN: You’ve even said that this is an attempt to privatise and turn it into an American-style system

CG: It is an attempt to privatise the NHS

AS Shaking her head with eyes shut

CG: We are not against competition

AN; Turn it into an American-style system

CG: Turn it into a mixed funding system with a state funding so core services with individuals

AS: Interjection

CG: There is nothing in the bill that prevents that from happening

AS: But that’s your opinion. That is not a substantial fact where you can say

CG: that is the opinion…

AN: The American system involves private insurance, that’s at the core, is that what they’re going to do?

CG: I would like to ask what there is in the bill that prevents that from happening and what you’ll find is that

AS: Interjection

CG: Is that there is nothing in the bill that prevents that from happening. You ask about competition. We are not against competition, we have never been against competition where it adds value to patients. What we are against is the full, fettered, any qualified provider where you have everybody competing for the same hip, the same knee.

Leadership in healthcare and the NHS bill

I confess I’ve always been sceptical about the idea of leadership. I haven’t seen a great deal of it in my career, and when I’ve read books about it I’ve come out more confused that I was before.

I think I was wrong.

I’m very struck at what difference leadership has made during the debate surrounding the NHS Bill. On the government side the Secretary of State, since the ‘pause’ last year, has been largely absent. When he does appear, it is noteworthy, not least because he’s usually getting shouted by a member of the public. If you think about the debate over the last year though, more often than not the government have sent someone else along to talk about the NHS bill. Some have fared better than others. I’m not convinced all the people who have spoken for the bill on behalf of the government have read it. Some of them don’t appear to have read very much at all. Not a great deal of leadership on the government side then.

I’ve been shouting about the lack of medical leadership in this country for some time. In 2006 I attempted to goad doctors into life in the BMJ (http://www.bmj.com/content/333/7569/660 – but behind paywall) as I though the profession were sleep-walking into the government’s changes. Not a lot happened – lots of doctors wrote to me to ask me if I’d organise opposition for them, but I wondered why it was they were looking to an academic to this.

I’m delighted that we now have a medical leader who has stepped up the mark, at some personal cost, to organise opposition to the bill. Clare Gerada has shown a great deal of personal courage and selflessness in taking on this role, often with what seems little support from the other medical representative institutions. I hope in time the public will realise how important her contribution has been.

Today the Royal College of Physicians have had an extraordinary meeting to discuss the bill. It sounds from the tweets (which the leaders of the College say they are unhappy about) that things were pretty fraught. However, the numbers of those at the meeting who believe it will damage patient care (89%), or who believe the bill should be withdrawn (79%) say a great deal. It is interesting, however, that there still seems to be something of a leadership vacuum. I don’t see the leaders of the RCP entering the public fray to argue against the bill. The contrast with the Royal College of GPs, led by Clare Gerada, is extremely noticeable.

Then we have the BMA. The BMA went through a process at the weekend where they voted to ballot their membership about pensions. Now the pension cause might be a worthy one, but my worry is that in focussing attention on pensions rather than the bill, the bigger picture is being lost. If the BMA were launching a vigorous campaign against the bill, of which pensions were a part, that would be one thing. Interviews with the leadership since the weekend, however, seem to be about pensions only. This is playing straight into the government’s hands, who will talk about self-interest at a time when organising to the greater cause of subjecting the bill to scrutiny is crucial. Again, I have to ask questions about leadership here. It is one thing to represent your members’ financial interests, but another to use that to argue for a greater good. And professionalism is meant to be about not only about doing good in your job, but having an eye on doing good for wider society as well. That’s why we give professionals good rewards and high status.

Now imagine how strong a united medical leadership could be – if the rest of the Royal Colleges and BMA had followed Clare Gerada’s example. Instead we’ve seen prevarication and delay, and even now there seems to be a reluctance, to use a quote from an RCP tweet today, to ‘rock the boat’. Instead it has been left to individual members such as Clive Peedell, who ran six marathons in six days to bring attention to the bill, and today Max Pemberton (http://www.telegraph.co.uk/health/9106880/Read-this-and-prepare-to-fight-for-your-NHS.html) , to make the case.

It is not the medics, but the government who are doing the boat-rocking here. They have a bad bill, badly presented by Lansley. If we end up with a thoroughly bodged reorganisation, which is surely now the most likely outcome, Clare Gerada will know she did all she could to prevent it. I’m really not sure the other medical leaders will be able to say that. Now we have seen leadership from Dr. Gerada, the contrast with both the government and other medical organisations serves them very badly.

Two wrongs don’t make a right – the NHS bill and BMA ballot on pensions

The NHS bill is still the catastrophe it was yesterday morning. Those of us who remain incredulous at the research suggesting improvements in care quality appearing in the second half of the 2000s were due to competition, are appalled that the government want to introduce more of into the NHS, and can see a whole range of problems coming from its extension. We believe private providers will take only the patients they want from public healthcare so leaving public providers with only those who are least well. Equally, it’s just about impossible to let comprehensive providers of care financially fail, so competition can’t provide the kind of incentives that its advocates claim. This isn’t a market that can work.

It is ironic that the most recent work from the team from the LSE (from Zack Cooper) that claimed ‘competition saves lives’ has now found that the benefits of expanding private provision are small or even negative – in the New Statesman’s leader this week it was claimed that any credit the government can claim for this work supporting their research has now comprehensively disappeared.

So while there is ever-more impetus against the bill, there is still the political problem of getting the government to step back from the bill and to admit they got it terribly wrong. This has been a struggle so far, and will continue to be.

Then yesterday, the BMA decided that they were going to ballot their membership about action short of a strike on pensions. It’s hard to over-emphasise how much harder this is going to make opposing the NHS bill. This was deeply politically naïve, and shows a remarkable lack of understanding of the history of healthcare in England.

Conservative governments have used two strategies to discredit doctors when protesting against NHS change. Strategy one, which we’ve already seen, is to point at them and say – ‘You opposed the creation of the NHS of course’. Now this is rank hypocrisy as the Conservatives voted against the NHS at its creation as well. The BMA were effectively excluded from the limited consultation that led to the creation of the NHS as Bevan preferred to talk to the Royal Colleges instead (largely because the Royal Colleges could make decisions on behalf of their members without needing a ballot). No wonder, when Bevan needed agreements he wanted to keep quiet, he went to them instead. Of course, the BMA weren’t impressed, especially as it was the case that their members (often GPs, and in the days before the RCGP) were those that lost most due to the creation of the NHS – private practice was made more difficult and many of their members did go on to real hardship in the 1950s (Taylor’s book on general practice covers this well).

So strategy one is for the government to say – ‘of course you doctors voted against the creation of the NHS’, when things were are bit more complicated than this, and the Conservatives voted against the NHS bill repeatedly.

Strategy two for the government is to say ‘you are only protecting your own interests’. Ken Clarke made jokes about doctors reaching for their wallets every time he talked about change with them, and more recently, ridiculous attempts at smearing Clare Gerada have appeared for investing in practices in London (which successive governments have more or less directly encouraged GPs to do, and when Dr. Gerada would probably gain more than she’d lose from the NHS bill). The underlying claim here is that doctors are only looking after their own interests – they aren’t really interested in healthcare reorganisation.

The BMA voting for a ballot on pensions has given the government an open goal to aim it by claiming doctors are only looking after their own interests – in early coverage on the BBC website yesterday Lansley had already started down this road, calling for the richest to make their contribution to helping stabilise the deficit as well as the poorest. From this point on, every government representative facing a doctor has now been given another line of attack. The BMA have made a big tactical error going ahead with this ballot now – when the NHS bill was still going through Parliamentary discussion. The government have comprehensively struggled with the terms of debate on the NHS bill, but this moves things back in their favour.

The issues of the NHS bill and medical pensions are separate ones – one is about a completely silly reorganisation based on ideology, the other about how we pay doctors. There are issues about financing that span both, but the two issues will now be muddied but the government, and the doctors accused of self-interest. And some of that mud will stick.

Those of us who oppose the bill have just had their job made harder. I especially feel profound frustration especially on behalf of Clare Gerada, who has shown the doctors what real leadership is, and Clive Peedell, who selflessly ran six marathons in six days to bring attention to the injustices in the NHS bill.

It is now crucial, however, to redouble our efforts to make clear that opposition to the NHS bill is not about protecting provider interests – it’s about making sure there is an NHS to look after ourselves and our children in ten years. If we don’t stop this bill, this is under threat.

The BMA made a big error yesterday, but that doesn’t mean the NHS bill is any less wrong. Two wrongs don’t make a right.

More on competition in healthcare

Amidst all the fun and games of yesterday, with Andrew Lansley being chased by pensioners, and David Cameron claiming he didn’t exclude people from his ‘NHS summit’, but rather simply forgot to invite them (!), more claims about competition in healthcare were made by the team of researchers from the London School of Economics. Zack Cooper, is the lead author of this work, appeared on Radio 4 yesterday, and his work is given prominent place in the Telegraph today (http://www.telegraph.co.uk/comment/telegraph-view/9093565/Only-the-inefficient-need-fear-NHS-competition.html).

The sad thing is that, frankly, I don’t believe the journalists reporting this work so favourably have actually read it, and if they’ve read it, I don’t believe they’ve understood it. The paper is an application of difference-in-difference analysis, is full of algebra and technical language, and so is hardly a relaxing read. Do these journalists really understand this paper? Really? If they had any clue what it said, they’d realise for a start that the findings don’t support the present reforms but those of the previous government – they support public competition finding little evidence for extending private competition as the NHS Bill is doing.

However, there are big problems with the research that need to be worked though (again).

Last year Cooper and his colleagues claimed that ‘Competition saves lives’, again from a working paper, which was subsequently published in the Economic Journal. Along with others, this research seemed to me to be so full of holes that we published a response to it in the Lancet. You can get Cooper’s original working paper here (the EJ paper is behind a firewall) http://eprints.lse.ac.uk/28584/ and our Lancet response here (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61553-5/fulltext). You can find more on this topic at Allyson Pollock’s website at http://allysonpollock.co.uk/

Now Cooper is claiming that competition improves efficiency, using much the same methods and same data. You can find more coverage of the paper here (http://www.guardian.co.uk/society/2012/feb/20/nhs-reform-competition-improves-hospitals) where Cooper is reported as saying ‘”We found two core findings. Clearly competition between NHS hospitals improves productivity, quality and efficiency. But when they opened up competition to private sector in 2008 it didn’t improve results,” said Cooper.

But here’s the problem. Competition, in itself, doesn’t do anything. Competition doesn’t save lives, or make hospitals more efficient. People do.

What Cooper and his colleagues have completely failed to show is the link between the variable which they have called competition (which we and others have disputed actually measures anything like competition), and the outcome – either improved efficiency, or lives being saved. They make vague allusions, as economists are want to do, about markets and their powers, but they actually have no data or evidence for a link.

When pressed on this, economists say things like markets cause ‘incentives’. There is an irony here. Economics is meant to be about how people make choices, but people are entirely absent from work like this. Instead, they are presented as being rational automatons that simply respond to whatever changes they discern in their environment – they follow ‘incentives’.

But what were the incentives this research is referring to? Are hospitals actually short of demand? If so, why are there waiting times at all? Only if hospitals were short of demand would they have to compete, and they aren’t. Equally, even if hospitals were short of demand, how would this change clinical behaviour? These links simply aren’t made in this research.

Competition, in itself, doesn’t do anything. It interacts with health workers, their professional standards, local cultures, existing practices, hospital infrastructures, GP referrals, patient discussions and a whole range of other things in complicated and unpredictable ways. I still don’t think there is competition amongst public hospitals in the NHS – I’ve yet to see anything like persuasive data it is happening because they aren’t short of demand for their services. And even if we got the point where there was competition, then any claims about it causing something would have be shown by careful research showing exactly how it was having effects of any kind. Simply asserting that markets are having some kind of magical effect is bizarre.

What is the problem the NHS bill is meant to solve?

I think it’s important to ask what problem or problems the current NHS bill is/are meant to be addressing. Before we can talk about evidence, and whether or not the reforms are backed by them, we first have to know what it is they are meant to achieve.

I confess I still don’t really know.

Thinking about the last year or so there has been a range of problems put forward by the government, but none have been made consistently by them, and all have struggled to find much in the way of evidence or support. It’s almost as if the government believe that, if they present enough problems, one will eventually find support and stick. So far, it hasn’t worked.

Way back in 2010 the original White Paper (remember that far back?), perhaps oddly, didn’t really make much of case. When compared with Labour’s 1997 and 2000 documents, it’s pretty hard to find exactly what the reforms were for. You might have thought a White Paper on NHS reform would start with a diagnosis, and then give you the treatment. What happened here, however, is something rather odd – except for fleeting glances we are given the treatment without the diagnosis. I’m no medical doctor (as we academics like to joke, I have a proper PhD), but that does seem to be going about it wrong to me.

The lack of diagnosis did not seem to deter the government from cracking on. I was surprised that the responses to the White Paper didn’t seem particularly vexed about the lack of diagnosis, but perhaps we can put that down to wanting to appear co-operative with the new government.

After the Bill arrived, however, things started to get less cosy.

One of the first stabs at making a case for the reforms was based around healthcare in England was  falling behind other systems, and that if the NHS was world class, extra lives would be saved from those who have died from heart disease, respiratory disease and cancer. You can find Chris Mason taking the arguments for these claims to pieces here (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html)

So if the reforms aren’t about standards of clinical care. The government seems to have got this wrong. How about another claim – that in order to meet the expectations of patients, the NHS needs to be improved?

The problem with this claim as it seems that NHS satisfaction from patients keeps hitting record highs. During the listening exercise it was at the highest level since the patient satisfaction survey began in 1983, and at nearly twice the level it was at in 2001 (http://www.bbc.co.uk/news/health-12805586). By December 2011 it had risen even higher (http://www.patrickkeady.org/well-done-nhs-70-up-from-34/).

Now again, there is room for improvement. But given the NHS keeps scoring higher and higher for satisfaction, it hardly seems that this is something that justifies a major structural reform.

Okay, so if it’s not clinical problems or patient satisfaction, what else might it be? Well how about productivity? The NHS got big rises in funding during the 2000s, so now its productivity has fallen, and in an era of austerity that surely needs addressing, right?

Well, again no. Nick Black from the London School of Hygiene has claimed that declining productivity in the 2000s is a myth in his recent work and that ‘a fuller account of the evidence reveals like substantial gains in productivity-gains in evidence-based practice, patient outcomes and patient experiences’ (I’m delighted to cite the Telegraph on this just to show non-partisanship (http://www.telegraph.co.uk/health/healthnews/9074733/Falling-productivity-in-the-NHS-is-a-myth.html).

Black goes on to say that ‘If the main reason for the Health and Social Care Bill is a lie, the upheavals it will produce are entirely unnecessary. This is further evidence to kill this damaging and dangerous bill’. Hardly high praise for the reforms.

Okay, so what else could it be?

How about that the big rises in funding in the 2000s mean that the NHS is now really, really expensive, and so we must find ways of reforming it to reduce the burden on the taxpayer?

Er, no. Sorry. The UK’s spend per head is only just above the average for the OECD nations, and remember, this is after years and years of much less spending on healthcare in the 60s, 70s, 80s, and 90s. We spend less than Germany, France, Sweden, Ireland(!), as well as a range of other nations including the US (as you might expect), Canada (that you might not), the Netherlands, Switzerland, Denmark, Austria, Belgium, and Iceland. So if we are expensive, they are more so. (http://www.oecd-ilibrary.org/sites/health_glance-2011-en/07/01/g7-01-01.html?contentType=&itemId=/content/chapter/health_glance-2011-60-en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2011-en&mimeType=text/html).

So how about the reforms needing to happened because the NHS needs the extra capacity from the private sector in order to meet increased demand?

Well, here’s the thing. The NHS has been using the private sector since the 1980s on ‘waiting list initiatives’. We are now at the point where it derives 25% of its total revenues from the NHS (http://www.hsj.co.uk/comment/leader/a-weak-private-sector-is-bad-news-for-the-nhs/5040671.article). So the private sector in the UK is now financially dependent on public funding. Remind me again which sector is meant to need the other one again? The NHS has been using private facilities for thirty years – we don’t need reforms to use the private sector as extra capacity.  Although it is a pretty good indicator that we ought to be spending more in public healthcare rather than less that this has been allowed to persist.

So. If the NHS reforms aren’t about clinical standards, or patient expectations, or productivity, or unsustainable levels of funding, or meeting extra capacity through private sector, what else are they for?

Well, how about this? We need the NHS reforms because it will make health services more locally responsive by delegating control to local doctors. That story’s certainly been tried a few times.

Well, again now. Have a look at the ‘organograms’ at http://abetternhs.wordpress.com/2012/01/31/scrutin/, and claim again there will be less bureaucracy after the reforms. So again, they aren’t about this.

Finally, we saw an intervention from the Secretary of State himself http://www.hsj.co.uk/comment/opinion/andrew-lansley-competition-is-critical-for-nhs-reform/5041288.article.

Here Lansley argues that competition is necessary for NHS to reform to make it more innovative, and he gives the example of the development of the music industry from records to CDs to mp3 players as an example of what he has in mind.

Are you kidding me? The NHS is not like the music industry – unless you are of the same mindset as the Institute of Economic Affairs (http://www.iea.org.uk/blog/how-to-abolish-the-nhs) and want to abolish the NHS, you can’t be allowing freedom of entry and exit into healthcare – with anyone licensing themselves to be a doctor and any organizing setting itself up as an NHS provider (even in the reforms they have to be both ‘willing’ and accredited). You can’t just set yourself up in healthcare. Equally, the NHS itself does not really produce medical technologies, it provides healthcare. It buys medical technology from the private sector when it has been proven both to work and be cost-effective. We don’t need the NHS reforms to do this – we’ve always done it. So I confess I don’t understand Lansley’s argument – it seems to more or less say ‘trust the market, it’ll be great’. I seem to recall the Labour government  saying a similar thing to the City of London in 2007 (if you feel like inflicting pain on yourself, read this, given just before the financial crisis hit (http://ukingermany.fco.gov.uk/en/news/?view=Speech&id=4616377).

So, there we are. I’m still none the wiser as to what the NHS reforms are for.

These reforms are a bill in search of a problem to attach themselves to. In the academic literature this is call a ‘garbage can’ approach to policymaking – a solution in search of a problem. Not evidence-based policy, but ideologically-driven policy. This may not even be conscious – let’s be honest, there’s little above that Labour weren’t advocating before the 2010 general election, and Alan Milburn has censored the government for betraying his NHS reforms (http://www.telegraph.co.uk/news/politics/8578022/David-Camerons-NHS-reforms-are-now-a-car-crash-says-Alan-Milburn.html ). As such, it’s hard to argue it would have been better under Labour.

The lack of a clear reason for the NHS reforms leaves it easy for people to find links between Conservative electoral donors and the reforms and accuse them of being ‘in the pocket’ of the private sector who might gain from the reforms (let’s go to the Mirror for a change http://www.mirror.co.uk/news/uk-news/nhs-reform-leaves-tory-backers-105302). This is what happens if you can’t explain why you are doing something, and leave yourselves vulneralble to personal attack.

Time for a complete change of direction for NHS reform? You bet.

It’s not enough just to ask for evidence-based policy

One of the common refrains coming from a range of very sensible people concerned with NHS reform, as well as in other public policy areas, is that it should be based on evidence. ‘Evidence’ is often implicitly or explicitly counterposed with ideology. This all sounds very sensible – don’t we want our governments to base their policies on evidence, and wouldn’t that be better than if they were based on ideology, anecdote or opinion?

Mmmm.

The problem here for me is that having evidence about something policy-related is not enough in itself when it comes to policymaking. In medicine it’s often possible to come up a degree of confidence about what the best treatments are (at least on average), but even then we need trained professions to help us work out how that research applies to us individually, or how it can be used to better organise clinical care. The trick is in interpreting the evidence to make a diagnosis of what might be best for the patient, who will themselves have opinions and biases they want incorporating into the decision.

The situation is more complicated when it comes to policy. Economists like large data sets from which they can derive models. Social policy academics often like surveys. Sociologists like to go and talk to people to find out what is going on. The findings from different kinds of research can often end up in open contradiction, with researchers claiming that the ‘evidence’ leads to entirely different conclusions.

What this suggests for me is that it’s not enough to ask for policy to be based on evidence. In the present NHS reforms, for example, the government do have evidence for at least some of the elements of their reforms – take the Cooper research on competition for example (its published form is here http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0297.2011.02449.x/abstract, but you can find working papers if you google the title terms). Now this research, using what economists say is cutting edge methods, claims that the use of competition in the NHS has ‘saved lives’ and an obvious policy response is to say there should be more of it. However, researchers from other traditions (including me) have argued this work is deeply flawed (at http://www.lancet.com/journals/lancet/article/PIIS0140-6736(11)61553-5/fulltext). On the Lancet website you can also find a response from the original researchers, as well as from the critics.

What this kind of dispute points to, is that it isn’t possible simply to say that policy should be evidence-based – research evidence can often come to very different conclusions.

So what do we do? Throw up our hands and give up? No – I think the situation is retrievable.

A way out of this is to use evidence in a different way, and try and aim for what we might call ‘argument-based policy’. Argument-based policy would ask researchers and perhaps more importantly, policymakers, not what their evidence is (that comes later), but instead to go through the argument for what they advocate step by step, and only when we they have made that clear should they present the evidence they have for each of those steps.

This may sound like a tedious process for you, but could act as a clarifying device to find out what policymakers are simply asserting, and what they claim they can actually demonstrate using evidence. Equally, it requires researchers to be very clear not only about what they are claiming, but also how they went about making those claims, and on what data and assumptions they rest.

To give an example. In the present NHS reforms, the government are claiming that CCGs will liberate the NHS by reducing bureaucracy and putting more power in the hands of responsive local GPs. The argument seems to be:

1. At present PCTs commission local services
2. PCTs commissioning local services means that local people and local clinicians are not much involved
3. Putting GPs (and others) in control of commissioning local services would engage them in commissioning local services
4. Putting GPs (and others) in control of commissioning local services moves decisions closer to patients and make GPs more aware of budgets, so making decisions more efficient
5. Therefore. Putting GPs (and others) in control of commissioning local services would liberate the NHS, make it less bureaucratic (so more efficient) and move care closer to patients.

Now expressed this way we can break down the claims. (1) was fairly uncontroversial at the beginning of the reform process (although we might question how much discretion PCTs often had about many of the services they commissioned). (2) is less obvious – there certainly were problems with PCT commissioning, but whether it was a big problem that clinicians were not involved requires research evidence that we could go through in terms of its claims in a similar way. The government hasn’t made much effort to show this though.

(3) is a kind of truism – if we get GPs to commission, then they will be more engaged in commissioning. However, this doesn’t mean that GPs are best placed to do the job, or that CCGs will actually represent their views any better than PCTs did (it depends which GPs end up commissioning care, who is advising them, how decisions will be made etc). All of this requires careful engagement with evidence, as well as further work explaining exactly how this is meant to work. In terms of (4) I co-published a piece a few years ago that reviewed evidence from GP fundholding, for example, that suggested that it led to a fall in patients satisfaction and only a one-off fall in referrals or prescribing (http://www.bmj.com/content/333/7579/1168.full). That would seem to suggest there the GP/patient relationship is rather more complex than (4) suggests, although there might be other evidence showing otherwise. We’d have to work through both and try and work through the assumptions and differences of the work to come to a judgement. In any case, it seems fair to say that the conclusion at (5) is being made prematurely.

What I’m asking for here is that we become more transparent about our claims, and that they are structured into an argument form so they can be tested and debated. Policy prescriptions are messy and complex, but can be made more straightforward if we can look at them as arguments, and then to look for the evidence that supports the premises and conclusions of those arguments in a more systematic manner. Then, at least, we can agree where we differ.

We are wrong to want a benefits cap.

We find ourselves facing a number of social policy problems at the moment – the government’s bungled NHS reforms, the scandal of social care for the elderly, the confusion over public sector pensions, and, most recently, the plans to put in place a £26,000 limit, per family, on benefits.

This last proposal, the benefits cap, is said to be very popular amongst the British public, and so the Prime Minister is relaxed about the House of Lords voting against the reforms earlier in the week, as he knows he can force the legislation through in the Commons. Of course this is all a bit odd – the chamber made up of a bunch of Bishops and Peers supporting the poorest in society while the ‘Commons’ is in support of it, but we live in strange times.

Intuitively as well, there’s something in the idea of a benefit cap that is appealing. Why should families receiving benefits get paid more than the average wage (that’s the £26,000 figure)? Why expressed this way, it seems to make a lot of sense.

However, perhaps we’ve lost sight of why we are paying these benefits in the first place. Why do we pay them?

I’m very struck that in philosophy texts, social policy is regarded as being something that is made towards people who are not fully competent. Strawson, for example, talks about situations where normal interpersonal expectations breaking down putting us in an ‘objective’ attitude towards others where they are unable to meet our normal expectations of them. Social policy is the means of supporting them if they are unable to ever meet those expectations (in the case of physical or mental disability) or if they are temporarily falling short.

This argument has a great deal in common with that made by Anthony Giddens around the ‘social investment state’, where social policy is used to support people between periods of worklessness, to enable them to get themselves back on their feet and back to normal. I think this is also very much the view of both New Labour and the Coalition Government – the norm is work and independence from the state. If this is your starting point, then it’s not much of a leap to saying that you want to limit benefits, not only in terms of the amount paid out or the duration you can receive benefits – benefits are meant to be there until you can get yourself back to work. If you have a disability, equally, benefits should be paid permanently, but not to put you in a position better than that of the average family. There is a logic to all of this.

However, I’m not sure the logic is quite right. If we go back to Strawson we can find the first problem. If we all had the same opportunities at birth, and we were all conscious of the need to work hard at school, then there would be grounds, perhaps, for saying that the state should provide only temporary support. But this simply isn’t the case – I was lucky to have parents (but don’t tell them this) who left me to my own devices, but also made clear the costs of not doing well at school. I’ve also had a safety net from them in case I mess up – I know there is always a bed for me if everything else goes wrong. I don’t think for a second everyone else had this – I was lucky.

If we think about this in terms of equality of opportunity, then I didn’t lose out too much as a result of coming from my family. I didn’t go to a posh school or have links to the rich, famous or powerful, but had enough security to make my own way. Some people have a great deal more than I had, but many people had an awful lot less.

If social policy is about supporting people unable to find work and be financially independent, then it seems to me we must first have offered them some degree of equality of opportunity. We (as a country) try and provide this by providing free education up to a certain point, and free access to healthcare, and some kind of access to housing in case of an emergency, but also, by supporting families through paying benefits. But this isn’t enough to approach equality of opportunity – there are families with vast amounts of inherited wealth, access to schools which have the very best results, faster access to high quality healthcare than the NHS is able to provide, and lots of safety nets in terms of money so family never have to worry about where the next pound is coming from.

If we fail to provide some degree of equality of opportunity – and we are an awful long away from doing this – then it’s not fair or reasonable to withdraw benefits from people, most of whom will have had few chances to become independent and autonomous in their lives.

If work is the arbiter of success and independence, then we have another problem. It isn’t as if pay always seems to make a great deal of sense. We give financiers who do little or no social good millions and pay teachers, nurses and social workers often derisory incomes. It’s pretty hard to argue that such highly qualified people should get paid so badly, especially when they are trying to do social good. It is also no accident that the very highest paid jobs tend to be made up on people who come from backgrounds of considerable wealth – another barrier to social mobility.

What should we do? If the key to this is equality of opportunity, then we need genuine lifelong learning where people are able to access education at any point, paid for by the state. We can set a limit on this (I think one PhD is probably enough) but we must give people the chance to retrain at any point in their lives. And we must pay them living support while they do so (is this really worse than paying benefits?). We must target support at the families which have the fewest opportunities – we can’t possibly expect them to be independent of the state where there are no jobs, no training opportunities and no expectations of ever participating fully in the economy. If people unreasonably refuse sensible opportunities there might be grounds for us suggesting that benefits be capped, but surely not before then.

We also need to take a big gulp and tax inheritances properly. Inherited wealth has to be a massive source of inequalities in outcome. Why on earth do we support families retaining advantage within their own members? There is something instinctive about wanting to give your own children the best possible opportunities, but if we all do this through inherited wealth rather than through their individual merits then we restrict social mobility and fix inequality. This can’t be right.

Equally, we must look at pay and work in this country. The market is not some semi-sentient, self-adapting system that is always right. Markets have led to bankers taking away millions while crashing the economy. I have argued elsewhere that responsible capitalism is about reducing the gaps between the richest and poorest. I think this is absolutely necessary – what kind of fairness leads to people going through years of training and education only to find themselves earning less than the average wage? Too often as well the best jobs go those not with the best ability, but because they are like (affluent, white, male, posh schools) those who went before them. Look at the cabinet for goodness’ sake! How on earth can we have representative democracy when these people come from completely different backgrounds to the rest of us. Unfortunately this goes for the majority of those in senior positions in large companies. There are exceptions (which we conspicuously celebrate), but the rule is that to be successful you need to be of a certain type. That’s got to be against the long-term (even medium-term) competitiveness of the economy.

I find myself with mixed views on the benefits cap. It isn’t fair for the state to pay families sometimes considerable amounts where they make no opportunity to give anything back. But it equally isn’t fair to expect people to be independent of the state where they have not had access to the same opportunities as many others. We need to remember what the causes of poverty are, not just treat its symptoms. And that’s why a benefits cap without a far greater equality of opportunity is unfair.