Scotland and Europe

July 19, 2016

To work out Scotland’s place as a nation and within Europe we need perhaps to look at where we are now, and then where we could be going.

Scotland has had its own Parliament since 1999. Since then it has taken on an increased range of powers in areas devolved to it (including health, housing, law and order for example). As a result of the 2014 Independent vote, it is acquiring powers to set its own rates of taxation (which it has so far not used) and the ability to put in place its own benefits. It does not control immigration, defence or foreign policy. In the 2016 EU referendum 62% of Scots who voted, voted to remain, making it by some margin the strongest pro-EU nation within the UK.

Scotland feels different to England. The transport infrastructure works (when Scotrail aren’t on strike, and even then it still better than it is in England). Healthcare has not been subject to the repeated changes that England has suffered from, but the health of Scots is in need of improvement. School education has fallen behind where it ought to be. Higher education is free for Scots, creating a very distinctive feel to undergraduate courses that is less consumerist than in England. Towns and cities are less divided in Scotland – you see the full range of human experience much more readily than the more segregated approach down south.

And of course, Scotland is significantly more pro-EU than England. This might be down to the SNP managing to get its voters out in ways the English political parties failed to do. It might be due to Scotland being a beneficiary of EU funding (although that didn’t stop Wales voting to leave). It might be due to the SNP managing to be a counter-voice to whatever is going on in England, and so voting EU in Scotland being about contrariness. I’d also like to think it is about a recognition that Scotland might actually be more European than England – and with that a sense that Scotland has the potential to be a great Social Democratic nation in ways that England seems to have long abandoned.

So what about the future? Well there are some issues. Scotland is in the UK, and the UK as a whole has voted to leave the EU. Yes, the vote was itself a failed attempt by the Conservatives to deal with their own militant anti-EU wing. Yes, it was a campaign that showed all the very worst aspects of our media and which demonstrated the paucity of our political discourse. My own view is that we really need a vote on the terms of any Brexit negotiation before leaving the EU, as that is the only way to actually compare EU membership with something tangible. But assuming we don’t get that, Scotland is going to exit the EU along with the UK.

The next logical step would be for Scotland to demand another independence referendum, and the first Minister has already indicated that, if she believes that is in the best interest of Scotland (and I think the clue might be in her Party’s name), then that should happen. I worry about independence because Scotland is a small nation, and it seems to me that much of what it seeks to achieve in terms of social justice depends on risk pooling that might need to work on a larger scale than its 5 million souls. Equally, I worry about Scotland not yet having a strong view of what it wants to be if separate from the rest of the UK.

One view, expressed by Sir Nicholas Macpherson, is that Scotland could become a low-tax, small-state economy. I hope this isn’t on the cards. Along with low-tax tends to come low-skill, huge job insecurity and an economy based upon being cheaper than anyone else. That seems to go directly against the words of our First Minister so far, and would also go against the grain of Scotland’s links with Europe.

Instead, an alternative is to look to Scandinavia and to work toward a high-skill, high-investment economy. A country that respects public services and invests in them. This is going to mean taxes go up. But I believe Scotland has the infrastructure – and the standard of living – to support this. Equally, if we are to address inequality and move towards social justice, there is little more powerful than progressive taxation to address that. It will mean significant investment in our schools and in improving health services, hopefully without the repeated drives to reorganise them seen in England. It will also mean devolving powers to local areas and giving them the resources to effect real change. This seems to me to be something Scotland can achieve if its government sets its mind to it. A distinctive anti-austerity message that is pro-European and very different to what is going on in England.

If Scotland is able to make a case in these terms, then I’m sure it would be welcomed into the EU in the future. But in the meantime Scotland can be European by remembering its links to European ideas of social justice and by putting in place a clear plan for achieving them. The Scottish Parliament already has sufficient powers to achieve this, so it can be done irrespective of any future independent referendum. It would also make a much stronger case for independence if Scotland was able to show itself to be even more different to England in terms of its approach to taxation, welfare and public investment, and through this difference, be able to show its concern for European social justice. Now that really would be a vision for Scotland in Europe.

 

The failures of our governments

July 7, 2016

In the wake of the long-awaited publication of the Chilcot inquiry in the decision to invade Irawq, the newspapers in the UK today are full of stories of government failure. Perhaps the most biting is the linking of the decision to invade with that of the generals of World War One – the suggestion that we are ‘Lions led by Donkeys’.

Chilcot has laid bare the decision-making style of the Blair government. We are left with the view that the decision to invade was made well before the government ever admitted it, and that the intelligence upon which it was based was deeply flawed. The report suggests that the invasion was premature, with other options still being available. It suggests that the process by which the legality of the invasion was established was not a good one, and asks questions about how Cabinet government was organised more generally. It expresses the strong view that there was no credible plan of what to do after the invasion.

Perhaps we need to locate this story in some context. First, the Blair government had done some pretty extraordinary things by 2003. Blair had intervened personally to get the Northern Irish peace process on track, and secured an historic agreement. Blair had also used his influence to get Clinton (and NATO) to get involved in the war in Kosova, and we should not forget that, even though that intervention was too late, Blair’s intervention saved many lives. After this, of course, came the election of a new US president who Blair appears to have been concerned to be seen to be working with. And the horrific events of 9/11.

One story of context, perhaps then, is of Blair, on the back of his successes in intervening abroad (and closer to home), coming to over-estimate his abilities. By 2002/3 he was not short of confidence, with foreign policy success to point to and a dominant electoral position at home. He was also establishing a relationship with a new president in a complex foreign policy environment. This was the era of policy ‘delivery’ – of being seen to get things done.

The factor I think that is most concerning though is the ability of the Blair government to be able to make foreign policy largely as it saw fit. The is a structural feature of the UK Parliamentary system – with a large Parliamentary majority, the government has considerable power to do as it likes. We have few checks and balances (the Queen can in theory refuse to sign Bills, but to do so would provoke a constitutional crisis, and the House of Lords can be eventually over-ruled if it objects).

I’m afraid the decision to invade Iraq is the most awful representation of a more general problem. Our governments, if they have any kind of majority, are able to pass really dreadful legislation and put in place really awful policy. Parliament isn’t good at stopping bad decisions because the whip system forces MPs to vote in line with their parties rather than really scrutinising the proposed changes. Equally, we push far too much business through Parliament for decisions to be subject to sufficient scrutiny. My own research suggests that the debates that do take place are not deliberative in the sense of trying to actually work to find the best policy solution. Instead they are often partisan and superficial.

The decision to invade Iraq did not involve legislation, but was debated in Parliament. The debate was held at the last minute, and, we now know, the decision to invade was based on poor intelligence. It is hard to see how this resulted in good decision-making.

The more general problem then, is that government is often able to pass poor legislation which isn’t scrutinised well. Governments aren’t made to work through the available options. They aren’t forced to for research evidence. New Secretaries of State often push through hugely expensive changes and reorganisations with little other than faith underpinning them – look at the changes to the NHS, to the benefits system, and to schools. These have cost billions and billions and were changes often based on little more than someone in power having a big idea.

It doesn’t have to be this way. Perhaps we need to reverse the logic of our legislative system. One approach would be a precautionary one where any changes would have to be shown, through research, to be necessary beyond any reasonable doubt, before being legislated for. Another approach would be to restrict government to a limited number of Bills per year, but to structurally ensure that they were debated fully, based on research based on pilots, and with free votes for MPs who were expected to not only engage with the debates, but show that they did so through their contributions. That would move us rather closer to something approaching a deliberative process.

Such processes would almost certainly have avoided the invasion of Iraq. But they would also save billions of pounds in careless and reckless changes to public services and the country, very little of which actually results in much by the way of benefit.

 

The turkeys, the farmers and Christmas

June 27, 2016

Once upon a time, a group of farmers couldn’t decide whether to have Christmas or not. It had been a long time since the last Christmas. It was a lot of bother. Some of the farmers liked it, some did not. As they couldn’t agree amongst themselves, they decided to ask the turkeys. So they did.

Some of the farmers said that, if we had Christmas again, the white turkeys could get rid of some of the turkeys with different coloured feathers. The farmers said ‘The turkeys with the different coloured feathers aren’t like you. They have made the farm a worse place and we can’t afford them. This is called ‘getting back control’.

Some of the farmers said that, if we had Christmas again, the turkeys would have more money spent upon them. The farmers said ‘If we have Christmas, then we will spend more money on looking after you’. They put a big sign up on the wall of the farm saying how much more money they would spend.

The farmers who didn’t want Christmas told the turkeys that Christmas would be really bad for the turkeys. They got their farmer friends to say the same thing. They got their famous friends who weren’t even farmers to say the same thing too. The farmers who wanted Christmas said the farmers who didn’t want Christmas were just trying to scare the turkeys.

So the turkeys voted. Just over half the turkeys voted for Christmas, and that meant the decision applied to them all.

On the day after the vote, bad things began to happen. The farmer in charge went missing from the farm. Some of the white turkeys started being very rude to the turkeys with different coloured feathers. They said they weren’t welcome on the farm any more. The farmers who promised extra money for the turkeys said they didn’t really mean it. The sign promising extra money to the turkeys disappeared.

Then it turned out that Christmas was really expensive. So there was less money for everyone. Some of the turkeys who voted for Christmas said they didn’t expect it to happen – they were just angry with the farmers and wanted to put them to extra trouble. Some of the turkeys who voted for Christmas said that they didn’t actually expect Christmas to come – that they didn’t realise that other turkeys would vote for Christmas too.

But Christmas was coming now. Even though no-one was in charge at the farm, the knives were being sharpened, and the cranberry sauce prepared. It was only then the turkeys of all colours realised what a mistake they had made.

The morning after the EU referendum

June 24, 2016

Today is a day in which we must choose our words carefully – something some of those prominent in the referendum campaign seem to have lost sight of. But we also need to try and work out what has happened, and what it means. Here’s a first try.

First, let’s be clear about why this referendum was called. It wasn’t because there was a big national mood for a vote on membership of the EU. It is because the Conservative Party were engaging in one of their periodic in-government feuds over EU membership (remember John Major resigning in 1995 over similar battles) and reckless promises being made about offering such a vote should the government win a majority in 2015 (which they didn’t believe they would). That’s the old history here – but we should remember why the vote happened in the first place.

The ‘remain’ campaign focused on the economic consequences of leaving, with most (but not all) senior government figures making that case. Again, this is odd, in that if the economic consequences of leaving we so catastrophic you’d have thought it was a bad idea for us to be having a referendum. At least some of this seems to coming true as both shares and the pound are falling significantly this morning.

The ‘leave’ campaign found its trump card in immigration. It is easy to dismiss those who voted leave as intolerant, or even worse, racists. Happy, satisfied people don’t blame others for their predicament though. It is very noticeable that many of the areas of the country that have received most EU money ended up voting heavily to leave. Why did that happen?

One explanation is that the major political parties have been battling over the centre ground for so long (a legacy of the 1990s) that they forget about everyone else. And many, many people – at least the two million needed to turn the EU referendum to one voting for remain – haven’t seen their living standards rise for two decades. The major employers in their areas have left, either having been bought out by overseas companies which subsequently left, or having been left behind by an increasingly service-based economy. It is not hard to see why you might, in those circumstances, blame immigrants for your situation. We know that wages have been bid down in some areas of the country because of immigration. We didn’t do enough to help people who have lost their jobs and livelihoods in the last thirty years – all the more tragic as this is likely to this leading to their lives becoming shorter and far less fulfilled. This inequality helps none of us, and is an easy source of discontent onto which must nastier claims about people from other countries can be grafted.

In Scotland discontent has been channelled more positively into nationalism. The BBC map of voting shows Scotland as a sold ‘remain’ voter. The Scottish people seem to blame immigrants less, and have hope in independence, which now has to be back on the cards again as the nation has voted so differently to England. Scotland shows that inequality can be directed into a more positive movement, something from which England needs to think about urgently in terms of devolving national governance.

This morning I feel most sorry for colleagues and friends from Europe who live in the UK and who will be wondering what their future holds. We need to find compassion for those who have lost their livelihoods and standards of living over the last twenty years, and who blame immigrants for this. But we don’t need to put even more people in that position.

As I write this I see the Prime Minister has declared he will step down in mere months. Financial markets are judging our vote result badly. What we must now do, assuming no further vote will follow, is to address the reasons why so many millions feel so disaffected. Blaming others for our problems doesn’t take us very far. We have a lot of problems that are of our own making – right across England and Wales there are millions of people who don’t see much of a future for themselves. Nigel Farage suggests the vote is one against Big Business. That is very much not the case – I fear that those governing the UK will now remove labour rights which originated in the EU, and push us into an even more extreme version of a flexible labour market, with lower pay and less rights, than even before. That won’t address the problems I’ve outlined above. I wonder who those who will lose out will find to blame next time?

The EU referendum debate – the arguments for and against

June 13, 2016

The EU referendum has been billed as the single most important vote given to the public in a generation. Two official campaigns exist – one urging us to consider ‘Britain stronger in Europe, with the other simply claiming we should ‘Vote Leave’. Videos have been compiled, letters written to newspapers, celebrity endorsements sought, speeches made.

In the month of May 2016 a range of speeches and other, longer statements and letters from both campaigns were made. Ten were collected from the ‘Britain stronger in Europe’ website and nine from that of ‘Vote Leave’. They were then  examined statistically to aggregate the key themes that each side is making using cluster analysis – which looks for words that are likely appear at the same time. This gives us a clear idea of the key ideas each side is using, and the way they are assembling their arguments. What do we find?

The Vote Leave campaign has five thematic clusters of ideas. The first is concerned with freedom and democracy – suggesting that both will be enhanced by us leaving the EU, which is often described as an unaccountable and elitist. The second argues against European Court of Justice and its ability to prevent the deportation of criminals. The third cluster of terms is less organised, arguing generally against the Prime Minister in relation to energy and gas prices, and against the security concerns the ‘Britain stronger in Europe’ campaign have raised. The fourth cluster of ideas in the Vote Leave campaign are around economics, making arguments about exports and economic growth rates, as well as unemployment, and casting  doubt on ‘Britain stronger in Europe’ predictions about a loss of growth should the country vote to leave. The fifth cluster of ideas brings together arguments about wage pressures resulting from increased immigration and the struggle for families they can lead to. The top five key terms from this cluster, along with their relative weights within it, are shown below.

Figure 1 – Vote Leave, Cluster 5, top 5 terms.

eu blog chart

‘Britain Stronger in Europe’ has data that coheres around four main clusters. The first explores how Britain should remain because to leave would harm the environment and investment in Britain more generally. The second cluster of ideas are around worker’s rights, especially for women, and around the guarantee for more equal pay that the EU ensures. The third cluster of ideas is based on agreements and the co-operation that the EU offers, and the costs of leaving for the economy. Finally, the last cluster is about how the referendum offers a clear choice for the British people with a clear decision ahead of us, based on the fact available, for us to vote to remain.

As such, the debate in May seems to be taking place on rather different footings. The Vote Leave campaign is about freedom and democracy, with Britain Stronger in Europe talking about worker rights. The Vote Leave campaign talks about the EU as being unaccountable and elitist, but with Britain Stronger how it offers us access to co-operation and trade agreements. Vote Leave is arguing against the economic case being made by Britain Stronger, which the latter maintains is compelling, whereas in a wider context Vote Leave is making a case for spending the EU contribution on the NHS instead. Vote Leave is talking about immigration, but Britain Stronger seems largely to be staying away from that issue, suggesting instead that the facts of the debate are clearly in favour of us remaining.

What this suggests is that the Vote Leave campaign is appealing to freedom, democracy and putting an anti-EU message forward, alongside suggesting immigration can be reduced and employment made more secure, if we exit. There are often strong emotions involved in these issues. The Britain Stronger campaign, on the other hand, is trying to mobilise a vote based on economic data and warnings of economic costs should be leave, while at the same time trying to appear more rational and less emotional. Whether Britain Stronger’s lack of engagement with some of the big issues of the Vote Leave campaign – freedom, democracy and immigration – will harm it in the vote itself, remain to be seen, but surely the message to remain in the EU needs to engage with bigger ideas.

 

Criminalising clinicians is not the answer to care failure or neglect

November 18, 2013

It has been widely reported in the last few days that doctors, nurses and managers will face jail if they neglect patients (see for example http://www.theguardian.com/society/2013/nov/16/doctors-face-jail-if-patients-mistreated). Press coverage has suggested that this links back to both the Francis Report into Mid-Staffordshire and the Berwick Report into patient safety (the former is correct, the latter, not really, as I’ll come back to). The idea is that, by putting in place criminal sanctions, a deterrent will be put in place to prevent the wilful neglect of patients. I think this is the wrong way to go about this.

The NHS does have a problem in terms of care provision. Part of this is sheer scale – when you have that many organizations all of which are providing NHS care, there will be some clinicians somewhere not doing a job. They may even be engaging in wilful neglect. But sadly, there will be poor care somewhere. The question is, how can minimise poor care as much as possible?

The government plan to make neglect a criminal offence depends upon such an offence being a deterrent. But just about the most robust finding we have in psychology is that, if you want people to do things better, you should appeal to their intrinsic motivation rather than by putting in place extrinsic rewards or sanctions. In more everyday language, if you want people to do a good job, you should appeal to people’s pride in doing a good job rather than trying to pay them to do it, or by threatening them if they don’t. This finding applies double when you are dealing with highly-qualified professionals. We want our clinicians to do a good job, so we need to have systems in place that appeal to their pride in caring, not trying to pay them to do it better, or threatening should their care standards fall. Of course we need systems in place to hold clinicians to account for the care they provide – but threatening them with jail really isn’t the answer.

A key question for me is why does bad care happen? How is it that people who became carers with probably the best of intentions end up neglecting patients? The answers are not straightforward. It can be the result of having to work in dreadful circumstances, brought on by a lack of resources and dreadful leadership. It can be the result of gradually falling standards due to the tolerance of poor care from others. We need a great deal more research to really understand what happens when care fails. But threatening people with jail should they fail to provide good care on the grounds that it will act as a deterrent ignores how and why bad care was being provided in the first place. It assumes that carers are making rational decisions to neglect patients, when the real situation is always more complex and difficult than this.

A second key question is whether the principle of prison-based deterrence ought to apply to our policymakers. If we are going to prosecute carers, then why aren’t we prosecuting government ministers for neglect in policymaking, leading to an NHS reorganization that was not based on research, which wasted billions of pounds, fragmenting care, and demoralising staff? If the government are so sure that deterrents work, why aren’t they making themselves subject to them too? Or is it, perhaps, that by sending a few lowly-paid nurses to jail (as has happened at Mid-Staffordshire, under existing health and safety laws) we can pretend we have dealt with care provision problems and move on, rather than looking harder and thinking this through more carefully?

Francis did recommend that neglect of basic standards be a criminal offence. Berwick was much more circumspect – I read his findings in suggesting that, only in extreme cases should criminal proceedings be used, as expressing the bare minimum agreement with Francis rather than supporting the earlier report. Berwick talks instead about the collective responsibility of care teams, and about supporting carers – the language of punishment isn’t really a part of his report. I think he was right in this. By appealing to the reasons why people became carers in the first place, by supporting them in their jobs, and making sure they have the resources they need to do their job, then we have the best chance of minimising neglect and reducing care failure. Sending people to jail won’t help.

Targets, performance management and the NHS – what happened at Colchester?

November 14, 2013

Last week, we received a report from the Care Quality Commission that showed that cancer care records at Colchester hospital had been tampered with. Inspectors went into the hospital in August and September, and found 22 of the 60 records that they looked had been compromised in some way. It seems that senior managers were alerted last year (2012) to what was going on, and carried out an internal review, but this did not stop the practice. By way of context, Colchester was one of the 14 hospital trusts with high mortality rates that was included in the Keogh review, and although 11 of those trusts were subsequently put into special measures, Colchester was not. It is worrying that, even under increased scrutiny, the tampering with care records was not picked up earlier. It also seems that Unison and the RCN were trying to raise alarms, but that managers dismissed their concerns. The CQC only seems to have picked up the problems when – in the words of BBC correspondent Nick Triggle, they were told ‘exactly where to look’ (www.bbc.co.uk/news/health-24833412). The trust is now in special measures.

What does all of this tell us?

One view is that this is just what happens when you impose targets on staff in a particular way. Where staff have no ownership of targets, and will be blamed for not achieving them, then they have good reasons to try and ‘game’ them. I don’t know who the originator of the pithy phrase ‘hitting the target but missing the point’ is, but that seems to go on a lot in performance management systems. Targets make us narrow our focus, and the danger with that is, if we forget why we are chasing the target in the first place, we can end up behaving rather perversely. I can manipulate the figures to make it look like I have met the target (as seems to have been the case at Colchester) or I can hit the target and stop – saving my effort for the next time period or going to other activities instead. Or I can stop engaging with activities that don’t have targets attached to them, even if those other activities are worthwhile too. In other words, narrowing focus can be extremely useful, but it can also lead to problems where we forget all the other things that presently aren’t being measured, but are important in our job as well, or where we decide, for whatever reason, to simply lie in the statistical return for the target.

So, if targets cause problems, should be abandon them? There was an interesting discussion around this on twitter, where several people suggested that target-based systems are inherently flawed, and so we would be better off without them. I was interested to see several clinicians, however, suggest that targets are both important and can be useful. They made two main arguments.

First, that we need targets because without them we wouldn’t have seen the improvements that the NHS has achieved in recent years. Think of waiting lists – imposing maximum waiting time targets has meant that managers and clinicians have found ways of driving down waits, and surely that has to be a good thing. Provided that the reductions in waiting time are genuine, and that we haven’t ended up distorting clinical priorities, that seems a good argument. Effectively, we are saying that by finding a target that is in an area that is important, and focussing on it, then they can be a means of driving improvements. This can come through diverting resources into areas we need to improve, or by reviewing care pathways to find bottlenecks or efficiencies. Wherever it does come though, a target can be a means of focusing attention and driving improvements.

A second argument in favour of targets is that they can act as a means for clinicians to be able to challenge managers to provide additional resources. The logic is that, if a trust looks like it is going to fail to meet a target, then clinicians can go to managers to get more resources to try and improve performance against the problem target. If the point I raised above was about focus, this was is about diversion – about diverting resources and attention from one area to another – another area that looks like it has a target that won’t be met. Again, provided the diversion of resources is justified, this seems to me to be a good thing. But of course, if the target being chased is not as important as the area losing the resources, then this isn’t really optimal.

What I’m struck by is that you don’t need centrally-set targets to focus, and you don’t need them to allocate resources sensibly either. Surely it’s the job of our managers and clinical leaders to work out what the staff working with them need to be doing? Targets can help us focus on what is important, but do we really need them to be centrally-imposed us to treat them seriously? I would hope that clinicians are more than capable of working out what they need to do each year to make things better, set targets for themselves to that end, and be held to account for them. I’m not clear why the government needs to be involved. Equally, if the health needs of an areas are such that resources need diverting, then surely we can expect clinicians and managers to work through that debate and come to sensible conclusions. This won’t be easy, as decision about what to prioritise are also as much about politics as they are about evidence, but the alternative, where government sets the targets for us, isn’t the right way forward either as this ignores the importance of local context. What health services in Durham (where I work) need to prioritise is very different from health services in York (where I live).

What I’m arguing for here is for targets to be decided in a bottom-up fashion, by clinicians and managers working out what needs doing, and then being held to account for doing it. And those targets need to be understood as goals rather than fixed measures that we can simplistically tick off once achieved. Patient care isn’t like that. If we get our clinicians and managers to agree goals together, and hold them sensibly to account for their achievement, then we have a way forward in improving services that people will have bought into, and which will be about improvement rather than punishing people for things that they believe they have no stake in.

 

The closing of the walk-in centres

November 11, 2013

Warren Buffet once said that the difference between a conversation and commitment is a cheque. There’s certainly something in this. If you believe in something you should pay for it, right? So, if one in four walk-in centres are closing, that would suggest that this is because the NHS doesn’t value them sufficiently to keep them open. The NHS isn’t willing to pay for them, ergo, then don’t have value.

But this logic only works if all funding decisions are made rationally. There are at least two reasons why this isn’t the case with the walk-in centres. First, because it seems that many people are waiting longer than want to (or sometimes should be waiting), to get a GP appointment. I don’t have a problem getting a GP appointment in a reasonable time, but understand this isn’t always the case for others, especially those in big cities. If the walk-in centres are providing extra needed capacity, then it would suggest that closing them isn’t right – especially if, as Monitor report, the people using them will end up in A&E instead. That isn’t going to help anyone, and is going to cost a lot of money. We have been told that the walk-in centres are ‘popular’ in press coverage this morning, but I haven’t seen good research examining whether their case-load is made up of non-urgent cases, or whether they are providing a valuable additional service. It seems we don’t really know enough about walk-in centres actually do, and that is half the problem.

A second problem with the idea that, if walk-in centres were useful, then the NHS would pay for them, is that is assumes a market-based rationality. It assumes that patient need and patient choice is driving the system, and I’d be amazed if that were the case. We have been told that the walk-in centres are ‘popular’ as I mentioned above – in which case they should be getting the funding they need, and it seems this isn’t the case. And even if the walk-in centres were popular, that still doesn’t mean they are actually serving a clear health need – we ought to be asking deeper questions as to why people who go in them aren’t visiting their GPs – whether they can’t be bothered to book an appointment, or can’t get one. Whether they actually need to see a doctor, or their needs could be better met through seeing someone else (or perhaps even, no-one at all). Healthcare isn’t a consumer good, as individual patients are usually not in the position to know if the person seeing them knows what they are talking about or not.

So closing the walk-in centres may or may not be a good thing in terms of providing better care. It may be that CCGs don’t want to pay for them because their members aren’t working in walk-in centres. It may be that commissioners don’t have the research to show whether walk-in centres are valuable or not. It may be that we’d all make greater use of walk-in centres if they were more convenient to get to than their own GPs – especially for us commuters.

What the closures do show, however, is the deep irrationality of the purchaser-provider split. If the NHS needs the extra service and capacity that the walk-in centres offer, it should be making the funding available. This shouldn’t be about the localised purchasing decisions of CCG, which seem to be largely unaccountable and unjustifiable here, as these decisions don’t appear to be being based on any particular evidence.

 

What kind of market is the NHS market?

October 20, 2013

This week a merger between two hospitals in Dorset was blocked by the competition commission, on the grounds that the move would be anti-competitive (http://www.bbc.co.uk/news/uk-england-dorset-24559766). The two hospitals aren’t happy, especially Poole hospital which is apparently in a pretty bad financial state, and was depending upon the merger acting as a kind of financial bail-out for it. What are we to make of this? What can it tell us about the emergent NHS market?

Well, as I keep on complaining, the NHS is not a market. Using the term ‘market’ suggests that we are talking about something like perfect competition, a theoretical model never observed in the real world, in which there are lots of small purchasers, lots of small providers, freedom of entry and exit from the market from both purchasers and providers, and it is cheap and easy to get in and out. There is also perfect information about what is going on, and participants that make highly rational decisions.

Now others (Alan Maynard especially) like to remind me that expecting the world to be this way is unrealistic. And that’s right. But in talking about ‘markets’ we are using the legitimacy of an idea (the perfect market) to underwrite a bunch of arrangements that are nothing like this.

Because over here in the real world, the NHS isn’t like this. We have large providers (both public and private) where we can’t let the public providers exit or go bust (although we might let private managers or even private providers take them over). We have private providers who can duck out, but we’ve still got to provide care so public providers will end up having to take their place (breast implants, for example). We have lots of small purchasers, but when they are up against big providers they will appear weak and disjointed and have little power. And where we have to pay for something complicated, like care, we may need planning and co-ordination – whether it is long-term care for the elderly (which is especially worrying given this (http://www.bbc.co.uk/news/uk-england-sussex-24579496)) or for cancer care.

Now look, I like competition in markets where I think I can make sensible choices. I like it that Samsung and Apple are driving each other on to make me better gadgets. But I still have no idea how I’m supposed to make choices in the healthcare market, and I don’t think my GP does either (and s/he is meant to be doing the commissioning on my behalf). We have put in place a system of buying and selling care that labels some providers as being effectively bankrupt when they may actually be providing really good care, and little or no sensible evidence showing all the effort and expense of having the market mechanism in place actually justified its costs.

So – back to Dorset. Should the merger have been blocked? Well, there’s very little evidence showing that mergers work, anytime, ever. They take years to get over, and just about never live up to the claims made to justify them. Mergers are generally a bad idea. But equally it is ridiculous to force hospitals to merge because they are in financial trouble. Surely the question we should be asking is whether they are providing a good service to their local people? Are they providing high standards of treatment? Are they giving good care? If they are, shouldn’t we be paying for their services rather than forcing them into dubious merger manoeuvres on the grounds of market legitimacies that are based on a theoretical model rather than anything in the real world? And if they aren’t, shouldn’t we be finding ways of driving up their standards rather than assuming somehow that better management can fix it?

The NHS ‘market’ isn’t a market in any kind of sense by which we usually use the term. To use the term market is to confer dynamism and innovation upon institutional arrangements that run directly contrary to providing the long-term, stable, and open-ended care that we need. More importantly, pretending the NHS is a market conceals the need to think very differently about how we can support care by organising things differently, and how we can arrange finances to support good care, rather than forcing hospitals to try and merge to avoid running out of money and being forced into private hands. That way madness lies.

Confronting obesity – a response to Max Pemberton

October 16, 2013

In this week’s Spectator (12th October) Max Pemberton makes the case that Britain must urgently confront its growing obesity problem. He takes us through an anecdote about a patient in a GP surgery demanding a pill that will allow her to not digest fat along with a range of alarming statistics (£5bn a year additional costs to the NHS with 300 hospital admissions a year due to obesity). He writes about other costs – Ambulance services having to replace their fleets to deal with obese patients and hospitals having to buy new operating tables, trollies and scanners. Max points to the failure of public health policy in terms of eating five fruit and veg a day, and suggests we now plan around obesity – assuming it to the both norm – rather than confronting it.

So what should we do? Max suggests we need to confront patients about their weight to get them to confront the reality that they are eating too much and moving too little. He accepts that some people may be genetically predisposed to weight gain, but that changing lifestyle can deal with this. The problem, he writes, is that we aren’t trying to lose weight any more – it’s an attitude problem. We treat patients as consumers (literally here, I guess) and then we are surprised that they won’t take responsibility for their weight any more. Obesity is not a disease, Max writes, – it’s a mindset.

I hope I’ve represented Max’s piece reasonably above. Is he right?

On one level, I think he is. Clearly we can control our weight by eating less and moving more. But it may not be as simple as that. Obesity is important because it is a growing and expensive problem. But it also challenges the way we think about our environments and what it means to be human in a fundamental way. Where we locate the blame for obesity tells us a lot about how we see the world.

We can locate obesity as not being our fault as individuals through two strategies. First, we can say it is down to the toxic food and drink environment we have created for ourselves. It is sometimes hard to move in supermarkets or corner shops for booze and crisp deals, and then you get to the counter and they try and sell you cheap chocolate as well (even WH Smith do this at present – I can’t buy a newspaper without being offered a family-size bar of Cadbury’s). There are studies from the US showing that many local shops offer their local populations huge deals on cheap but largely nutrition-free food and drink, and so little wonder they get fat. Suppliers of sugary drinks and convenience foods pay shops to take their products and display them prominently, crowding out more healthy alternatives. On this view we are having obesity foisted upon us by the food and drinks industry and government turning a blind eye.

Equally, we can blame our genes. Max talks about this in his piece – and no doubt some people do have a higher propensity to store fat than others. Hey – this would have been a genetic advantage not that long ago when food was scarce, but now it’s everywhere (see above), we get fat because our bodies are super-efficient at storing fat for the famine that now never comes (for us in the West, at least). Again then, not our fault.

But these two explanations, as Max points out, take choice and responsibility away from us. But we don’t all deal with choice and responsibility in the same way. Talking about personality types is always a simplification – but work done by Margaret Archer and more recently Graham Scambler points to some of us being autonomous in the way Max describes, some of us depending on others for validation more, and some of us having such jumbled and chaotic personal narratives that we struggle to make and carry through good decisions. Now if I’m autonomous I make my own judgements, and presumably can be held accountable for what I do in the way Max describes. But if I’m more likely to be looking for validation from others, then their views and lifestyles will impinge much more upon me. It’s no wonder that people with weight problems may live with other people with weight problems (be them family or friends). We want to fit in. We don’t want to be the ones not eating crisps or puddings, or seem fussy about what we have for dinner. Equally, for those with chaotic life narratives, who struggle to be consistent or make good decisions, it’s easy to see how eating convenience foods or buying the chocolate when it’s on offer to you, become the everyday decisions. Especially when you are trying to down work (possibly across several jobs).

The key thing is that what we eat and how much we move is a complex mix of the above. I’m lucky in having a job that means that most days I can arrange time to eat reasonably well, as well as being able to afford my own exercise equipment, so I can get up early and try and keep my weight under control. I live somewhere where I can access a decent range of foods without too many problems. I’m also lucky in that my wife is an excellent cook, and so much of the food preparation falls to her (I try and do childcare to balance this up a bit). All of these things mean that I can be held to account in the way Max describes. But many (most?) people aren’t.

Yes, we need to do more on obesity, and adverts with cute plasticine characters aren’t going to fix it. We need to hold those marketing and selling us nutrition-free food and drink to account – hell, let’s tax stuff that is making us fat as we should be eating less of it anyway. But we also need to make sure that better alternative are available, and educating kids better about food at school (I’m appalled at the rubbish they get taught there about nutrition). And parents, yes, need to do more as well about helping their kids be healthier, in terms of both diet and lifestyle more generally. And so do doctors.

So Max is partially right. But in simplifying this down to choice and responsibility, he’s missing out large parts of the story, as well as not questioning how why our health services are treating us as consumers, or asking our governments to act in the better interests either. We need a bigger and more encompassing strategy – leaving all this to markets will just keep making us fatter and more unhealthy where we allow money to be made in that way. But we, and our governments can change the rules to move us more towards the right direction, and to more effectively help those that need more support.


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