What do we do now the NHS bill looks like becoming law?

March 13, 2012

Given the lack of Liberal Democrat support for voting even for amendments from members of their own party on March 13th, it looks as if the NHS bill is likely to become law. I hope I’m wrong on this, as I’ve provided lots of reasons here why I think that’s a bad idea, but it looks like the fat lady may be singing on this one.

So what do we do now?

One thing that seems to be clear is that the the coalition government are confusing law with implementation. Just because something is law, it doesn’t mean it will be implemented. Remember internal market one from the 1990s? What happened there was that Ken Clarke got the medical profession so angry that even Thatcher moved him on, and put in place more conciliatory figures to actually implement the legislation. As a result, remarkably little happened.

I don’t believe that Cameron is a fool. I think what he’ll do now is get the Health and Social Care bill on the statute book, slap Lansley on the back, and move him on. He’ll put someone else in charge who will say things like ‘start with a clean slate’ and try and defuse things.

But to make sure this happens, the clinicians have to keep making it clear that they do not support the NHS bill – but that if the government will give ground, so will they. But the government must make the first move, and I think it will do so after the bill becomes law, and Lansley is moved on.

So action point 1 – it is crucial that the health organisation bodies keep up the pressure and make clear that the government needs to listen to them if they want this bill implemented.

A second point is that the implementation of the bill is in the hands of health workers up and down the country. You have the power now to decide how to deal with this mess, but deal with it you must. As my colleague Bob Hudson pointed out on March 7th (http://www.guardian.co.uk/healthcare-network/2012/mar/07/nhs-reforms-what-happens-bill-passed?INTCMP=SRCH), it is perfectly possible to take the government as part of their word and organise locally to foster co-operation, increase patient involvement and commission in a collective way to prevent any private cream-skimming. I’m afraid though, this will be in the hands of CCGs – it is therefore crucial that GPs and other health professionals get involved here to make sure that the worse elements of the bill can be mitigated.

Action point 2 – health professionals have to get involved in CCGs in order to mitigate against the worst effects of the bill

Third, we need to acknowledge that it will be necessary to behave in anti-competitive ways to sort out a range of long-standing problems in the NHS in England. We already have a fragmented system, notably between health and social care, and between acute and community health services. If we take the government at their word and try to drive genuine bottom-up change we will far greater collaboration across both of these boundaries. We can’t possibly meet adult social care outcomes frameworks without greater collaboration and more clearly defined care pathways that work directly against the grain of competition. Equally we have to go back to planning community services in such a way as to minimise unnecessary acute admissions. We will need CCGs to take a lead in driving service improvements across these boundaries to prevent even greater fragmentation.

Action point 3 – health professionals in CCGs need to take a wider view and look across their local health areas to work across the boundaries that have dogged us in the 2000s.

What we face potentially now is a tragedy of the commons. If all health organisations go into their bunkers and try and compete, we will see national framework goals missed, and an extension of the beggar-my-neighbour approach we’ve already seen far too much of between community and acute health services.

We need our GPs and other health professionals, through their roles in CCGs, to show us some serious leadership. It will take them away from their role with patients, and I still believe this a really bad idea. Our health professionals will have to work against the grain of a bad bill to make it work for their patients. They will need all our support in doing so.

6 reasons why the NHS bill should be dropped

March 12, 2012

Here is my attempt to explain what is at stake in Parliamentary debates around the NHS bill. I think, for me, there are six points I’d like to raise against which I have seen no sensible government response.

1. There is no democratic mandate for a significant reform of the NHS. In the 2010 election, no political party proposed the present reforms, or anything like them. There was next to no debate on the NHS before the election. We were assured by David Cameron there would be no ‘top-down’ reform of the NHS.

As there is no democratic mandate for the NHS bill, it should be withdrawn.

2. At best, the evidence supporting increased competition in healthcare is deeply contested. The government have made a big play on research from Zack Cooper and his collaborators showing that ‘competition saves lives’. Now I think there are substantial problems with this work as I’ve written on this blog, on the LSE blog, in the Lancet, and in future publications. But even if you do believe this research, it doesn’t relate to the new NHS form – it relates to the NHS between 2006 and 2010. The same researchers have found little gain from public/private competition (between 2006 and 2010 it was primarily public/public competition).

There is next to no research showing the NHS bill is supported by research. It should therefore be withdrawn.

3. The government have made no clear case for their NHS reforms. In the last two years we’ve had a variety of claims about getting GPs involved in commissioning (they will struggle to take on this role, and end up outsourcing it to others), about reducing bureaucracy (but the reorganisation will probably increase the number of tiers of organisations rather than reducing it), about improving clinical quality (when many of the statistics they have shown are out of date or just plain wrong).

The government doesn’t seem to know what the their own NHS bill is for. As such, it should be withdrawn.

4. The NHS bill has been so amended it is now completely different, and should be scrapped and started again. The lack of clarity from the government as to what their NHS bill is about has meant that they have made over a thousand amendments to it. The NHS bill that went through the Commons has now been substantially amended. It is almost impossible to predict what the effects of such amended legislation will be. This bill is incoherent – what on earth are we doing allowing something to become law that has been found to be so faulty it has been amended out of recognition.

The NHS bill has been amended so often it is incoherent and its effects cannot be predicted. It should therefore be withdrawn.

5. The NHS bill is not supported by those who will need to implement it. There are now very few clinical bodies that even remotely support the NHS bill. Most actively oppose it. The government began this process claiming they had the support of clinicians. This is simply no longer the case. They have not listened to the concerns of doctors or nurses or other health workers.

To be a success, an NHS reorganisation requires the support of those who will implement it. This bill is not supported by the vast majority of health workers. It should therefore be withdrawn.

6. The NHS bill is not supported by the general public. Opinion polls suggest that the majority if people in England would like the NHS bill to be withdrawn. Despite the government’s repeated reassurances and amendments, it seems they have no faith in this bill.

The NHS bill not only lacks an electoral mandate, or support from the clinicians who will have to implement it, it is not supported by the public either. It should therefore be withdrawn.

To be clear, the NHS needs to get better. It is already doing pretty well in terms of equity and efficiency, but does need to improve its clinical outcomes. However, it almost impossible to see how the present reorganisation will make things better. The reorganisation is costing billions, and causing disruption to no clear end. We need to start this process again and ask what we want our NHS to look like in the future. We can then start to work out how to make the NHS better. This reorganisation, however, is a waste of time and money. The NHS bill should be withdrawn.

The NHS bill as a failure of democracy

March 10, 2012

My overwhelming feeling about the NHS bill now is how it represents a comprehensive failure of democracy.

We didn’t vote for either the Conservatives or the Lib Dems to reorganise the NHS in this way. It wasn’t in their manifestos, and this wasn’t a part of the 2010 election debate or even the coalition agreement. There is no democratic mandate for this reorganisation.

The government have still failed to tell us what the reorganisation is for. They present claims about making the NHS less bureaucratic, but this simply isn’t the case – the bureaucracy that has built up around commissioning is now far greater than that of the PCTs. Equally, GPs won’t be in charge of commissioning as they will be heavily controlled because of the bureaucracy I’ve just mentioned, but also because they will be increasingly outsourcing their commissioning to private companies – why ask a highly-paid and highly-trained GP to make these decisions? Their skills and expertise lie elsewhere. Finally, there are arguments about making the NHS sustainable into the future. I have no idea how this bill does that. I would argue that the NHS has for the vast majority of its history, been relative to any comparative country’s healthcare, been starved of resources. We have only just now got up to about the OECD average spend on healthcare. If there is a healthcare spending crisis, then other countries have a much bigger problem, and that actually we have some years of under-investment to catch up on first. In sum, there has been no sensible reason given for this reorganisation – the government are not being open and clear about their motives.

Third, the bill has now been amended so many times that confusion reigns about what is in it, and what not. In the last couple of days there have been angry exchanges in the media between Polly Toynbee and Shirley Williams about private patient caps. The question this raises for me is that, when you get to a point where serious figures actually disagree what is even in the bill because it has been so amended (well over 1,000 changes and counting), then you have failed to go through a democratic system of making a bill law. The bill is a mess, an undemocratic mess. The bill as it is now is very different from the bill that the commons originally voted on. I don’t doubt it would get through a commons vote again as the Lib Dems don’t seem to have grasped how the bill, in my view (and other’s) has the potential to transform English healthcare, but it should be voted on again as it is now so different. And if legislation can be changed this much through amendment, it no longer carries any legitimacy.

Then we had the nonsense this weekend at the Liberal Democrat conference, where one of the political parties in the coalition government voted against offering its delegates the right to vote against the bill in favour of a motion supporting it, and then voted against the motion asking Liberal Democrats in the Lords to vote in favour of the bill. Is this really the best they can do? It seems to me that the Liberal Democrats have lost any right to be taken seriously on this issue – it is too important to be this obfuscatory and weak, hiding behind your own nebulous bureaucracy rather than allowing an open discussion and free vote on something that clearly matters a great deal to your party.

The next point is the farce of the risk register. The last time we got into such a mess over releasing information was over Iraq under the Blair government. There seem to me to be few grounds for not making the register public, but the government have repeatedly refused, even in the face of the information commissioner demanding it be published. Now I don’t know what’s in the risk register, but had it just been made a public document last year we’d all be better informed. Surely that’s what democracy is meant to be about?

Next there are confusions over the research evidence base of the bill. John Rentoul, for example, in the Independent, keeps presenting the LSE research on competition which supports competition as straight fact when it is rather contested. This isn’t just my view (or Allyson Pollock’s). Bevan and Skellern reviewed this work in the BMJ last year and found significant gaps in it. To present this work as ‘proving’ competition works is premature, and even if you do still believe the work shows competition works, rather ironically, it actually shows Labour’s policies of the 2000s work, not that the NHS bill will work.

Then there are confusions over the implications of the bill. Allyson Pollock and her co-authors have argued it provides a basis for charging (or at least doesn’t preclude it). Others are more skeptical about this. But again, the problem here is that these matters haven’t been openly and democratically discussed – we are stuck with a heavily amended bill that makes little sense and which is no longer coherent. It is hard to debate a 450 page bill amended over 1,000 times which simply has not been adequately scrutinised in its current form.

We also have a distinctive democratic gap in terms of support for the bill. Opinion polls suggest the public don’t support it, and we know that just about every clinical representative group (with the exception of the Royal College of Surgeons and a couple of very small bodies) have now called for its withdrawal. This despite both Cameron and Lansley claiming until relatively recently that the bill had the support of those working in the NHS.

The NHS bill does not represent informed, evidence-based policymaking. The bill is now so amended it is a mess, and it puts in place a range of competitive dynamics and private commissioning support which may be irreversible, and over which we may have little democratic control in the future – I see huge problems over claims of commercial confidentiality, as we have had with PFIs.

The NHS bill represents a failure of democracy.

Competition and the NHS – reponse to Le Grand

March 9, 2012

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

March 9, 2012

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.

NHS competition and bad science – a reply

March 8, 2012

Henry Overman (http://spatial-economics.blogspot.com/2012/03/nhs-competition-bad-science-or-bad.html) makes a number of points about our blog on the LSE site (http://blogs.lse.ac.uk/politicsandpolicy/2012/03/05/bad-science-nhs-competition/) which I think are worth replying to.

His first general point is that our criticisms don’t reflect the various Cooper papers, and he cites our blog versus the Cooper papers.

This seems an odd strategy. Cooper has, in addition to his academic papers, published a range of pieces in the Guardian and FT (and in many other places), as well as in press releases and on Radio 4. He seems to have no problem with his main finding being represented as being ‘competition saves lives’. He therefore doesn’t claim, as in the first example on Overman’s blog entry that the ‘major improvements in primary prevention in general practice’ could be due to ‘primary prevention and hospital care’. Cooper is being very clear – he believes competition saves lives. To present the work in any other way is to misrepresent what Cooper has claimed from it.

Overman’s second point is that Cooper is clear on the mechanism for improving care – ‘Competition on elective care improves management which also happens to benefit AMI’. This appears to contradict his first point (that the major improvement might have come through primary prevention in general practice), and further muddy the waters by claiming that competition ‘also happens to benefit AMI’. What does that mean? Is that causal or not? Overman suggests AMI was chosen because patients have no choice in relation to it. This amounts to a causal chain whereby even the clinical areas which are not responsive to competition themselves, were affected by competition. Does this sound remotely credible to you?

Overman’s third and fourth points are that it isn’t necessary for patients to remember or make informed choices to provide ‘incentives for hospitals’. However, he doesn’t really explain what the incentive for hospitals actually were. Perhaps these incentives comprise of the additional payments that might accrue from more patients choosing a hospital. But, at a time when waiting lists were in place, there seems to be little incentive for clinicians to want to be chosen – in fact we might argue the opposite, that being chosen less would help clinicians get through their waiting lists. Because the paper does not actually work through any causal chain (despite Cooper calling himself an ‘empiricist’ in his FT piece), there is no actual data on how the incentives were actually received by any real clinicians or managers. That these incentives existed is simply inferred, not shown.

Overman’s fifth point is that the EJ is more than capable of reviewing work like this. I think my response would be that the paper has internal validity (which might have been what the reviewers were looking for), but simply does not capture the complexity of the phenomena it is meant to be investigating. If you are going to make claims that ‘competition saves lives’ – which is itself ridiculous – health workers save lives, not governance structures – then you’d better have some pretty strong evidence. In my view, Cooper and his co-authors don’t. They have massively over-generalised from narrow data, and timed press events publicising their more sensational findings to be taken up by politicians and journalists who haven’t even read their work. This isn’t good science.

What difference will the NHS bill make for patients?

March 7, 2012

The NHS bill, in a nutshell, passes budgets down to GP commissioning groups (which will be heavily supervised), and increases the scope of private provision in the NHS. What difference will that make for patients?

The government’s argument is that patients will be able to choose which provider they want, and hospitals and other providers of care will be forced to compete for their choices. They argue this will drive up standards of care.

I have profound worries about GP commissioning. I like GPs, but I’d rather them be thinking about my care than buying care for me. The skills of buying care are very different from looking after their patients. When GPs took control of budgets in the 1990s it actually led to a fall in patient satisfaction – we don’t know exactly why, but I’d guess it was something to do with GPs becoming focussed on costs and patients not getting the referrals or prescriptions they expected to (the first year of GP fundholding saw a fall in both). That might be a good thing – perhaps those referrals and prescriptions weren’t necessary? However, I’d really my doctor be focussed on providing care for me rather than having to worry about what it’s costing. At present, we can pool costs by having large commissioning organizations (the much-maligned PCTs), so if my care ends up being expensive, that can be balanced out by lots of other people not needing any care at all. In the smaller care commissioning groups I worry that expensive patients will come to be regarded as a significant cost to their particular GP practices – and that seems to be a bad starting point for thinking about their care.

The first benefit the government are claiming for their bill is that it will increase choice. Choice can be a good thing. For patients with long-term conditions who are able to become experts in their own healthcare, this seems sensible. Should ‘expert’ patients want to choose, having acquired the knowledge to do so, we should support them. But this is already largely the case – the expert patients programme has been in place for ten years now. What about the rest of us?

Let’s take a standard sort of treatment which both public and private sector can provide – a hip replacement. There’s like to be several potential providers here. So you need a hip replacement. Which provider do you go to? Well you might have a choice between waiting times, between recorded success rates (however they are defined) and perhaps might also base your choice on how far you are prepared to travel, or even if you are prepared to conduct your research, the type of hip replacements offered by each provider (ones made of metal seem like a bad idea given recent coverage  – and don’t get my engineer father started on how insane it was to use metal at all for this).

So there we go – a whole bunch of relevant factors. What next? Well you need to work out which are more important for you, somehow weight them, and make a choice.

Now you may find all of that an empowering process. I don’t think I would – I’d want my GP to tell me who would do my particular hip replacement best locally, and to go to them. That’s asking quite a lot of a GP, who is effectively taking the risk for me, as well as having to act as my researcher, but hey – she’s got seven years of medical training and years more post-qualification experience. I’ve got an ‘A’ level in biology. She’s probably better at this than me.

So there’s benefit one – you get more choice. You probably won’t get much of a choice over exactly when you’ll be treated by any particular provider (you’ll probably have to have private insurance for that, and even then the choices you are offered will be pretty constrained), but you can have a choice of which provider you get – provided of course all the information is available – and it probably isn’t. Which makes me wonder how you’d make a choice (and please don’t point me to the NHS Choices website which has very little of the information I’d suggest you’d need above).

Now let’s say you choose a private provider, and things don’t go entirely to plan. What then? This is where uncertainty raises its head. In your basic-NHS model, you go back to the same clinic that did the operation and they be expected to remedy things. If you’ve gone to one of those fancy private providers you may have a problem.

First, the private provider will still have to be there. They do go bust you know. If you are a few years in, there’s no guarantee they will still be around. If they are there, you might have an argument about whether they are responsible for fixing you up. Private medicine is based on profit – I’m sure the doctors working within it have good intentions (except those providing breast implants, given the PIP nonsense) but they do have a strong incentive to pass any problems away from them. So if you need additional care, they will either want to get paid for it, or want to pass you to another provider. This is pretty much what my mother-in-law experienced in the Australian system when her hip replacement was rather bodged. No-one was interested in taking responsibility and helping her – everyone wanted to avoid the cost she might incur for them.

So if something goes wrong, there’s quite a chance you’ll end up at another provider. The local comprehensive NHS hospital won’t be allowed to go bust, but will be under considerable financial pressure. Even so, it is likely to be your best option. You’ll probably have to go back to your GP and make another choice to get a referral, but it should still be possible. Then you can hopefully get some help.

However, the story doesn’t end there. To help recover, you might need rehabilitation. That will need you either to go to a hospital for another service, or more likely, receive a service in your home through a community-based service. The provider you meet with (you may need to make another choice here) for your service will need to know what your needs are, and will need to link up with your NHS hospital to look at your medical records. They may need to refer you on to other services – you may need to access specialist therapy of one kind or another. That’ll need a new contract with another service provider.

The whole point of all this is that, if you think that it can be difficult getting NHS services to join-up now, you ain’t seen nothing yet. Can you imagine what it will take to join up services across multiple providers from different organizations and all the contracts that will entail? And all the ways things will be able to go wrong? I’m not saying the NHS gets this right – but I can at least see how it’s meant to work in theory. I can’t even do that for the new arrangements, unless the mighty IT gods descend and create some kind of super-integrated system. That didn’t work out so well under Labour – over £6bn was spent to little effect.

So, from the patient’s perspective the big gain is meant to be more choice. I personally don’t want it – I want my local NHS to be good enough for me not to have to worry about choice. I’d rather save my choices for when I buy shiny IT equipment. The price of this choice is fragmentation. The more providers we introduce, the more difficult it is to see how the system can be joined up for any kind of care which isn’t really simple. And care, by definition, is seldom straightforward.

Patient choice, outcomes data and care quality improvement

March 6, 2012

Should we release clinical outcomes data to the public to inform patient choice decisions? The argument in favour of publishing outcome data is that it will allow patients will be able to make more informed choices. At a simple level, wouldn’t we all like to know that we were choosing the best possible treatment available to us, and to be able to act on that information?

I think that clinical outcome data should be released, but using it as the basis for patient choice is a mistake. We can do better than that.

My first objection is that not all groups will use outcome information in the same way. Not everyone has the capacity to understand outcomes data – it’s complex stuff, and often involves making trade-offs between waiting and quality, and quality itself can have measures that directly contradict one another. There’s a reason why it takes all those years to qualify as a clinician – our bodies are complicated. That means that measuring the performance of those who try and cure our illnesses and ailments is tricky. A few years ago I showed some surgery data to patients asking them which surgeon they would choose. They struggled to come up with any kind of meaningful answers – they found patterns in the data that weren’t there, and often came to the ‘wrong’ conclusions – they chose the surgeon with the worst outcomes. Coming up with a good format to publish information in, is a big barrier. We need something that will communicate clearly, but also not over-simplify. That’s a tough call, and it may not even be possible.

Equally, not every patient wants to exercise choice – indeed a number of surveys suggest that patients want reassurances their local healthcare provision is good, not choice. If it is the case that only particular categories of patient choose, then that creates a significant problem of equity.

This leads to my second objection. If we start trying to use outcome data for patient choice, where does the choice process end? How many providers to I look at? Do I compare everywhere? If I don’t mind travelling I might look at data for the whole country. The trouble here is that healthcare choices aren’t like choosing a microwave. If I get a bad microwave I might be cross, and it may take time to save up for another one. If things don’t go well after I’ve made a healthcare choice (especially on behalf of someone I love, like a child), then I’m stuck with cognitive dissonance. Should I have chosen something else? Did I do wrong? Sheena Iyengar’s book ‘The Art of Choosing’ gives a range of areas (including healthcare) where making choices can lead to long-term problems for people, even if they did everything in their power to make the ‘right’ choice.

We also have to place choice in the specific context of healthcare. We can’t let comprehensive providers of care fail – we don’t have the capacity or the political will to allow this happen. As such, we are stuck with our large hospitals, and the trick now is making the best of them. If people stop choosing the local hospital because of poor outcomes data, then that hospital will have its cost base undermined, but it won’t be allowed to close. Patient choice isn’t really a driver of improvement, it’s a kind of sop to make us think we are driving up care standards when we are really just trying to look after ourselves – and, as I suggested above, even that comes with potentially adverse consequences.

The problem is that the purchaser-provider split is an expensive nonsense. Choice doesn’t drive improvements. Commissioning doesn’t drive improvements. We have unused facilities in providers because purchasers can’t afford their use, and when those providers are NHS facilities with large fixed costs that simply sit around when not used, this is a dreadful waste of resource. We have hospitals dealing with emergency admissions because of gaps in community health services, but with no-one addressing the problem everyone knows exists as responsibilities are split between purchasing and commissioning. Choice feeds into the purchaser/provider logic, fragmenting service provision even further. This isn’t the way forward.

Improvements come from clinicians and managers working together to drive up standards. Outcomes data are a part of that – we need to hold clinicians and managers to be held to account for the service that they provide, and outcomes data are clearly one part of that.

But even more importantly, we need to be democratically holding our local health services to account. We need more than the old ‘health scrutiny’ role of local authorities – we need, in my view, for health services to be a part of local government so we can directly elect people to hold them to account.

Outcomes data can be a part of the democratic process to demand improvements. What defines us collectively isn’t our individual choices, but our collective decisions. We live in a democracy – and we need health services to be far more democratically accountable. Offering individual choices rather than facing up to the hard business of improving health services is bad for us all.

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

March 4, 2012

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

March 1, 2012

On 23rd 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, 23rd 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.


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