Archive for August, 2011

What we can learn from the QOF

August 31, 2011

I think the QOF stands as the most successful health reform, in its own terms, the NHS has ever had. What I mean by this is that it was designed to achieve a range of behavioural changes in GP practices through the introduction of its linkage between funding and points, and met those goals spectacularly well.

If I were cynical I might say that the lesson from the QOF is that we should withhold funding from doctors unless they conform to pre-agreed clinical frameworks. But I’m not entirely cynical, I think that’s only part of the picture. I think there are several more important insights about achieving change that come from the QOF.

First, the key thing about the QOF targets is that they were agreed in negotiation with the GPs first. There is dispute about whether they are evidence-based or not, but by agreeing the targets, they have become accepted within the profession as targets that are broadly legitimate. They are certainly more legitimate than the much broader, and largely centrally-imposed targets that are imposed on hospitals, and often resulted in ‘gaming’ as a result (see Hood, references below).

Second, by being specific and practice-based, the targets were seen as things which could be incorporated into the everyday life of GP practices rather than being about things over which clinicians had little or no control – again as was often the case with the targets used in hospitals.

Third, GP practices were given autonomy on how they met the QOF targets. Some made wider use of nurses or practice managers, in some cases GPs took on the work. Instead of saying how the targets would be met, practices had discretion and autonomy in working this out for themselves.

What all this adds up to is a process by which targets were pre-agreed, accepted as being legitimate, incorporated into the practice of care, and with practices working out ways of managing the load. The result was the targets being met spectacularly well. In NHS terms this is a remarkable result – can you think of a reform which has worked as well in achieving behavioural change.

Now some researchers reckon the QOF was a waste of money as it hasn’t led to improved patient outcomes, just to targets being met. I’m not a clinician, so can’t separate these out. But either way I think it offers us lessons for how we can better achieve behavioural change in the NHS elsewhere – there’s no reason why clinical teams in hospitals can’t set targets themselves and go after them in similar ways, or for managers to reward them for hitting targets in similar ways to the QOF. I’ve always been a bit baffled by NHS managers saying it was a mistake to drop targets after the 2010 election – if they felt that strongly they could always have kept them themselves – it’s up to them how they they run their hospitals – they don’t need the Secretary of State to tell them!

In all then, even if you don’t buy that the QOF has made things better for patients, it offers us valuable lessons on how to do the management of change. Wouldn’t it be good if we could focus on learning these lessons rather than spending our time having to deal with daft NHS reforms?

Some references about the QOF and targets

Checkland K, McDonald R, Harrison S. Ticking Boxes and Changing the Social World: Data Collection and the New UK General Practice Contract. . Social Policy & Administration. 2007;41(7 Dec):693-710.

Checkland K, Harrison S, McDonald R, Grant S, Campbell S, Guthrie B. Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract. Sociology of Health & Illness. 2008;30(5):788-803.

Edwards A, Langley A. Understanding how general practices addressed the Quality and Outcomes Framework of the 2003 General Medical Services contract in the UK: a qualitative study of the effects on quality and team working of different approaches used. Quality in Primary Care. 2007;15:265-75.

Hood C. Gaming in Targetworld: The Targets Approach to Managing British Public Services. Public Administration Review. 2006;66(4):515-21

Lovett J, Curry A. Quality improvement with the new general practitioner contract – myth or reality? Health Services Management Research. 2007;20:121-33.

Maisey S, Steel N, Marsh R, Gillam S, Fleetcroft R, Howe A. Effects of payment for performance in primary care: qualitative interview study. Journal of Health Services Research and Policy. 2008;13(3):133-9.

McDonald R, Harrison S, Checkland K, Campbell SM, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. BMJ. 2007;334(30 June):1357.

In spite of everything, in praise of GPs

August 30, 2011

 

GPs eh? Have you seen what the research says about them? They struggle to look after patients in the time they have to see them, find it hard to keep up with evidence, and lack the technical resources and training to do any better. They seem to think they are more consultative with their patients than the actual patients do, over-ride patient decisions where they think they know better, and even treat patients differentially based on how attractive they are (Bryan, Ford and O’Reilly references at the bottom of the piece).

Many health economists don’t like GPs either. They think that they have got loads of money for the QOF when their productivity may even have fallen since its introduction, and that the QOF itself isn’t really evidence-based so that paying them for achieving points won’t accomplish much in terms of patient care (Fleetcroft and Cookson). They would regard the replacement of face-to-face appointments with Skype-based consultations a good thing – bound to be more efficient.

Then, of course, we are asking GPs to do all the commissioning in the NHS when the evidence of what they achieved as fundholders in the 1990s is rather limited at best (Greener and Mannion).

This doesn’t add up to a very promising picture. It seems that GPs don’t treat everyone equally, are harried in terms of time, limited in terms of expertise, didn’t make a great job of commissioning in the 1990s, and have followed the incentives of the QOF to score as highly as possible on it.

But here’s the thing – what on earth are we expecting from our GPs exactly? The research above suggests that they tend to be nicer to people who are easier to deal with. Well – I’ll let you in to a confidence. I tend to be too. It suggests that they struggle to deal with complex problems in ten minute appointments. Perhaps we should ask ourselves why we are surprised by this – if I had to deal with every student who came to see me in ten minutes then I would probably be pretty bad after it after two or three.

It also seems that GPs are limited in terms of expertise. Again, do you know anyone who isn’t? Medicine is difficult, and because of that GPs will sometimes make mistakes. The difference, of course, is that when a GP makes a mistake, someone gets hurt. If I give a bad class, students don’t learn as much as they might have. I have yet, however, to actually harm anyone in a lecture theatre or seminar room. That doesn’t mean I’m more perfect than GPs, but that my job is of a different type – very few jobs are like those of GPs.

I also have to ask if it is legitimate to blame GPs for not being the best possible commissioners of care in the 1990s. Most teachers do a pretty good job, but if they had to buy University education for their students and monitor the result, they’d struggle as well. I’m still not clear why we think asking GPs to commission as well as provide care is a good idea – it can hardly be because they aren’t busy enough already. I thought the basis of adding value to an economy was specialisation (division of labour) – so why are we asking highly-qualified doctors to do something that they aren’t trained to do? Blaming GPs for not being good at commissioning is a bit like blaming solicitors for not being good prison officers – having a go at a profession for something related to, but outside their expertise and training.

We also seem shocked that GPs, when given a clear system of incentives to earn points through the QOF, have followed them and been really good at it. Why is that? We’ve asked a bunch of the brightest people in the country to play a care-based game, and they’ve aced it. Big surprise. If I was given points for teaching and research I think I’d vary my practice and score decently too. There are bigger questions of whether the QOF measures the right things, but you can’t blame the GPs for being good at it.

Now there are bloody awful GPs out there. There are also bloody awful professionals in every service or industry. Let’s not kid ourselves that the all-seeing market gets rid of them in the private sector – if that were the case it’s hard to argue that there would be many bankers left after the nonsense of 2007 and 2008. Again the difference is that when GPs are bad, really bad things can happen very quickly. The profession hasn’t always been on top of that, and needs to do better in dealing with its poor performers, but we shouldn’t blame GPs as a group . It does ask difficult questions of GP leaders though, and I hope they will continue to make progress to making things better.

In all, let’s try and remember to be grateful for our GPs. Most of them are pretty good. They do a tough job under difficult circumstances, and it’s about to get harder again through the introduction of commissioning groups.  GPs have flaws, but so do we all. Before you assume a GP is out to get you, or doing a bad job, I think you have to try and see the world a little from their own, very human, eyes.

References

Bryan S, Gill P, Greenfield S, Gutridge K, Marshall T. The myth of agency and patient choice in health care? The case of drug treatments to prevent coronary disease. Social Science & Medicine. 2006;63(10):2698-701.

Fleetcroft, Robert and Richard Cookson. 2006. ‘Do the incentive payments in the new NHS contract for primary care reflect likely population health gains?’ Journal of Health Services Research and Policy 11:27-31.

Ford S, Schofield T, Hope T. Observing decision-making in the general practice consultation: who makes which decisions? Health Expectations. 2006;9:130-7.

Greener, I. and R. Mannion. 2006. ‘Does practice based commissioning avoid the problems of fundholding?’ BMJ 333:Dec 2:1168-70.

O’Reilly D, Steele K, Patterson C, Milsom P, Harte P. Might how you look influence how well you are looked after? A study which demonstrates that GPs perceive socio-economic gradients in attractiveness. Journal of Health Services Research and Policy. 2006;11(4):231-4.

The NHS reforms and the responsibilities of the Secretary of State for Health

August 30, 2011

It became apparent over the weekend that the legal responsibility of the Secretary of State for the NHS is going to be removed as a consequence of the ‘hands off’ clause within the Bill (http://www.guardian.co.uk/society/2011/aug/29/nhs-bill-lansley-wash-hands?CMP=twt_gu).

The logic goes like this. Lansley is passing commissioning down to groups, and so for them to have autonomy and be responsive to local need, they need to be free from interference from the SoS. Now, if you buy the logic of the reforms, based on trying to achieve bottom-up improvement through more localised commissioning of services and of greater choice and competition within those contracts, then this makes a great deal of sense. If you are going to put in place a competitive marketplace, you don’t want the SoS intervening all the time messing things up, do you? That would distort the market, putting political expediency ahead of market need.

The problem is, of course, that there’s no market for healthcare in any meaningful sense, and the coalition no longer are proposing a decentred, bottom-up market led health service, but a monstrosity that combines the worst elements of private involvement and a huge number of new QUANGOs. The market based elements of the reforms were never going to work because they are based on unrealistic views of how markets do (or don’t) work. This is a market in which neither patients nor GPs know how to choose, where outcomes data isn’t easily summarisable to make care decisions, and where there is no price comparison. A strange market indeed.

Equally, the expansion of the NHS Commissioning Board and the creation of the additional QUANGOs in the compromises the government has made around the Bill, mean that we don’t even have a dysfunctional market to look to anymore – we also have an incoherent bureaucracy.

So we have gone from a situation where we have an dysfunctional market to one where we have a incoherent bureaucracy on top of a dysfunctional market. I have no idea which is better or worse. Both are pretty awful – if the NHS is going to remain on track it is going to depend on the good will of the clinicians, managers and other workers that remain within it. If any improvements occur, it will be despite the reforms, not because of them.

What we need at a time when the reforms looking like they could turn into a train wreck, is for someone to take responsibility for them. And at exactly that time, it looks like Lansley, in the name of market freedom, has written himself out. Presumably he’s done this so that, once the extent of the mess emerges, he won’t have to take responsibility for it, blaming it on the Commissioning Groups and the Commissioning Board, and demanding bottom-up change.

But if you create an incoherent institutional structure, you have to take responsibility for it. It seems crucial that Lansely is not allowed to get away with blaming others when his reforms throw up the problems that his reforms have created.

Evidence, research and healthcare–or beware prophets bearing simple answers to hard problems

August 29, 2011

Something that is very apparent if you spend much time hanging around on Twitter, or with policy people, clinicians or health managers, is that people from different backgrounds have very different understandings of what good evidence is, and what good research looks like.

I think the central problem here is that we expect all research to conform to the methods of the natural sciences. That means there is a tendency to favour experiments or experimental methods, and results which produce produce clear answers in relation to hypotheses. Where we can’t do experiments directly we try and mimic those methods as closely as possible.

There’s lots of good reasons for this. Scientific methodology has brought us a great deal from the laptop I’m typing this on, through to many of the medical treatments that can literally be life-saving. So it would seem it provides a high benchmark to which we must aspire.

However, I think that it’s a mistake to uncritically use natural science methods in the social sciences. The problem is that science presumes that we can close off the system we are investigating and control for individual variables. It also presumes that we treat the system as if its made up of objects rather than subjects, and that we can take large samples to check our results.

In social research none of these things is the case. Social research deals with open systems in which there are no clear boundaries between what we are investigating and their environment, where it is almost impossible to control for variables one at a time because of the complex interactions between them, where people can confound our results by behaving differently to the same stimulus on the same day, and where large samples may not be possible because we are dealing with whole social systems rather than discrete experimental settings.

The problem is that a great deal of social research still uses methods as if these differences don’t matter. So it concludes that particular interventions work, when it is extraordinarily unlikely that this is the case – they may work, but only in certain circumstances, for some people, some of the time. Yelling at me to do work might work today, but I may just ignore you tomorrow – in fact I might ignore you tomorrow because you yelled at me today, because the relationship between us is complex and not mechanical.

I think the way to get around this problem is try and be a bit more humble and a bit more theoretical. We need to be humble because nothing will work all the time. We need to try and find out when things have the best chance of working, and for whom, and to let those commissioning and asking for research, be they policymakers or managers, know that demanding magic solutions is going to lead to disappointment. We need to be theoretical in the sense of ‘there’s nothing so practical as a good theory’, coming up with pragmatic ideas that are sensitive to contexts, individuals and organisations, and to support those who have to try and make change happen. It isn’t just policymakers that need to demonstrate a more grown-up notion of what research can achieve, but also managers. Managers need to understand that they can generate a great deal of insight from social research, but there really are no magic answers we can provide in a series of bullet points.

We see a number of generic answers to making the NHS better, from the use of competition to making use of social enterprises or employee ownership, to greater local democracy and strong performance management. None of these things work universally, but many of them may work in some circumstances, some of the time. The trick is finding out where, when and for whom. But it is also crucial to be able to explain why and how. Anyone claims to have an answer to reforming the NHS but can’t explain exactly why their ideas should work, and exactly how, should be a cause of concern. And when I say ‘exactly how’, I don’t mean ‘by competition’ or ‘through incentives’ or any of the other vague answers academics are wont to give. I mean exactly how.

What all this adds up to is a different understanding of evidence for social research. The best we can do is to say that good evidence is that which explains what has the best chance of working, when, where, why and for whom. We also need to explain situations where it hasn’t worked, and to try and work out what we can learn from them. Both policymakers and managers need to be sceptical of researchers bearing theories and ideas that are more simple than this. We don’t live in simple worlds, and anyone suggesting that the answers we need to navigate through it are any simpler is very likely to be wrong.

The NHS Bill is a dog’s dinner but we may be stuck with making the best of it

August 25, 2011

The problem with the government’s attempts to make the NHS Bill more acceptable is that it has gone from being an ideologically-driven mistake to an incoherent ideologically-driven mistake.

I could understand what the first version of the Bill was trying to achieve. I thought it was a huge mistake, but could understand it on its own terms. Provided you are coming from a place where competition is always good, and GPs and patients are able to drive improvements in health services through their treatment decisions, it makes a kind of sense. As I’ve made clear frequently in this blog, I don’t think any of those assumptions actually hold any water, but they do make a kind of sense if you go through the Bill with them in mind.

The first version of the Bill, of course, also makes a great deal of sense if you read it as an attempt to increase private involvement in the NHS. Now that’s not new, if you read Norman Warner’s ‘A Suitable Case for Treatment’ or Player and Leys’ ‘The Plot Against the NHS’ or Pollock’s ‘NHS Plc’ you can see that this sort of thing has been going on for a while now. But I think we get more suspicious when the funders and friends of the governing party appear to have quite so much to potentially gain from such reforms.

However, by modifying and amending the Bill, it has changed from being unfeasible because it makes assumptions about competition and choice that will never work, to unworkable because it imposes a bureaucracy over the top of competition into a mess. What they’ve done is taken a model that isn’t likely to work and added layers of top-down control that make sure it won’t. The whole idea of competition and choice was meant to take the NHS out of the control of the centre, and to generate self-improvement within the system. What the new plans have done is to add a strong element of central control over this through the national commissioning board and its outposts, while still trying to impose competition on local health areas through Monitor’s new role (which is still ambiguous to say the least).

So what we’ve done is take an ideologically-inspired model that won’t work and wreck it – a dog’s dinner. So should we drop the Bill?

I think there’s a problem with getting the Bill removed – in what seems to me to be gross breach of democracy. This comes from the government effectively implementing their reforms before they had been fully agreed by Parliament. Circulars were sent from the DH actively encouraging NHS bodies to proceed as if the reforms are going ahead. All over the country PCTs and SHAs are losing staff, selling buildings, and not renewing leases. What this means is that we are stuck with some kind of reform, even if we would seek to oppose the Bill and get it dropped as being bad.

So what do we do? Seems to me that we have a choice of watching while the whole thing goes down or trying to get involved and help. GPs will have to decide whether they are going to be in commissioning groups, and then how involved they are going to be. I’m probably going to be trying to help public commissioning support organisations (former PCT staff) in the North East. So I’m trying to make work reforms that I think are entirely the wrong thing to do. I don’t see what else I can do. To mix a metaphor badly, those of us that care about the NHS are put in a position where we try and stop a dog’s dinner turning into a train wreck.

If we get the Bill dropped now, I’m not sure what we have left in terms of the current infrastructure. If we don’t, then we need to all do our best to stop the whole system falling to pieces. We all have difficult decisions before us.

We need to treat the expert patients programme with care–especially now

August 24, 2011

The expert patients programme should be one of the most progressive ideas in recent health policy. The idea is a great one – we empower patients with long-term (chronic) conditions to self-manage their own care. Studies from the US show how patients can meet this challenge by taking greater control of their own medication, going on courses that help them to do so  (http://patienteducation.stanford.edu/programs/cdsmp.html), and which are now available in various forms (including on-line) in the UK (http://www.expertpatients.co.uk/). Expert patients make less use of their GPs, and are encouraged to develop a deep understanding of their illness, supported by medical professionals as they need them. All good, yes?

There is a lot of good potentially here. It’s clear that we need to make more of an effort in the UK to understand our own health, with comparative studies showing we are somewhat laggardly here (http://www.amazon.co.uk/Culture-Health-Illness-Hodder-Publication/dp/0340914505/ref=sr_1_1?ie=UTF8&qid=1314174818&sr=8-1). We will also have increasing difficulties in dealing with long-term conditions as we get an older population and, according to the DH, one in three of us already has a chronic illness of one kind or another.

But there are also problems. My reading of the DH’s publications on this area, going back to 2001, seems to suggest that the issue of cost-saving is often at the front of policymakers’ minds. Getting people to be  self-managing when they want to be is one thing, doing it to save money is another. Wilson’s work (published in Health and Social Care in the Community in 2001) suggests that it is an expression of pastoral power, attempting to move the responsibility for chronic disease away from the the state, and my own attempt at contributing to the debate (published in Social Theory and Health in 2008) suggests the Expert Patient patient programme resonated with the previous (and I suspect current) government because it cast illness as a mental problem that with appropriate management techniques could be overcome.

What I’m trying to say here is that long-term conditions are a complex mix of clinical and self-management problems. Training for the Expert patient programme, on the other hand, tends to focus on it as a self-management problem. I’m very happy for patients who want to be less dependent on the NHS to take greater control of their care, but worry if that might be what becomes expected of them, or that pressure is put on patients to do it when they don’t feel equipped to do so. Presenting long-term illness as a management problem has a tendency to lose the clinical part of disease, and to make it a cost-saving opportunity. And that makes me very uneasy – especially if we are entering an age when GPs consortia might be looking at cost-saving on a much smaller scale than in the past with the abolition of PCTs.

I don’t think GPs will be directly applying pressure on patients to become self-managing (at least I hope not). But reviewing chronic cases and encouraging more patients down the expert patient line is a very definite possibility, and raises the question of whether the gains from the expert patients approach are quickly exhausted.

The people who want to become expert patients probably already are, who have found out about it for themselves, and want to become self-managing. Training courses might help support such patients, but they’d probably do it without them. There may be a group of people who don’t know about the self-managing approach and could benefit from it, but I’m not convinced this is a big group. It also seems that the benefits patients get from being part of the Expert Patients programme seem to stem mostly from being involved in the training rather than from reduced dependence on health services (http://www.medicine.manchester.ac.uk/primarycare/npcrdc-archive/archive/PublicationDetail.cfm/ID/225.htm), and that the benefits might be restricted to a highly-motivated group wanting to participate in the programme rather than being applicable to those with long-term conditions as a whole.

What this means it that it is difficult for the Expert Patients programme to free up clinical time by making patients more independent, or save much money. Becoming self-managing has a substantial up-front costs as patients are trained, and they may need a great deal of initial support to become more dependent later on. A report from the Multiple Sclerosis Society (Measuring Up) in 2003 made it clear that they saw little savings from the programme as a result of these up-front costs. The same report also raised questions about the availability of the training needed to make the programme a success.

We need to do all we can to get patients to be more responsible for their own health, but recognise that doing so is not just a self-management problem, but also a clinical one. We also have to accept that not everyone is going to want to become an Expert Patient, and any potential pressure on them to do so for cost-saving ends is deeply troubling. Putting health services on a basis where budgets are both under pressure and held by smaller units creates the potential for tensions such as these to come to the surface. We all want the NHS’s budget to be spent responsibly. But we also want it to serve the people who need it the most instead of making them think twice before calling a clinician because they think they are meant to be self-managing.

How patient choice can work

August 23, 2011

I’ve written a great deal in this blog about the problems with patient choice (for example, https://t1ber1us.wordpress.com/2011/07/19/the-trouble-with-healthcare-choice/), but thought it necessary to make it clear that I’m only against certain kinds of patient choice, and that’s only because I don’t think they work.

It seems to me that the present reforms, despite claims otherwise in the White Paper, are making the same mistake as Labour made in focusing too narrowly on choice of provider when being referred by GP. It is possible that they also want to be concerned (again, as were Labour) with getting patients to choose GPs more carefully too.

This is a pretty narrow conception of choice – it is trying to get secondary providers and GPs to raise their game by being threatened by what Hirschman referred to as ‘exit’ (http://www.amazon.co.uk/Exit-Voice-Loyalty-Responses-Organizations/dp/0674276604/ref=sr_1_1?ie=UTF8&qid=1314132333&sr=8-1). When faced with a market-like situation, we have three options according to Hirschman – exit, voice and loyalty. Exit is what happens when you go somewhere else (choose another GP or secondary provider), voice is when you try and get them to change their ways, often by threatening to leave or complaining, and loyalty (which he was admittedly a bit vague on) is when you decide to stick with your present provider.

Hirschman suggested there are considerable dangers in situations where choice is strong and voice is weak, as those that can easily move will do, and those that are left don’t exercise voice to improve things. I can imagine poor health providers being in a situation where the vocal middle classes don’t want to go to them, or to complain when they can easily move somewhere else. I know of schools that are a bit like this.

There are other problems specific to healthcare. Can you imagine threatening a GP with exit? Or you hospital consultant? Seems pretty anachronistic to me. I think most GPs and consultants are trying to do a good job and treating them in a transactional way isn’t going to help. This is made all the more silly because most GPs aren’t exactly short of patients, and most hospitals hardly short of demand for their services – an individual patient making threats isn’t going to cut much ice.

Voice tends to work better – you explain what the problem is and give the clinician a chance to fix things. This feels intrinsically more possible, but let’s be honest, the NHS has a terrible track record on complaints especially. This is an area where the NHS needs to do much better – but it’s not as if private healthcare is much better at dealing with complaints either so I’m not sure there is much to be learned there. But the NHS does need to improve in terms of voice mechanism, and wasn’t helped by Labour changing the way this was supposed to happen every couple of years (http://www.sdo.nihr.ac.uk/projdetails.php?ref=08-1808-245), or by the confusion over this in the present reforms.

Loyalty is about sticking with a relationship, and ideally a long-term commitment from both parties to get it to work. That seems more what I’d like my relationship with clinicians to be like. However, there are issues in terms of continuity of care even in GP surgeries, and both sides have to be making an effort for it to work out. But fragmenting services and putting them on a transactional basis favouring threats of exit, as the present reforms seem to want to, isn’t going to achieve this.

However, we can achieve loyalty by thinking about the way clinicians interact with patients. I wrote yesterday that what we can learn from CAM is that giving patients time and space can lead to good outcomes even if they underlying treatment doesn’t have much merit (https://t1ber1us.wordpress.com/2011/08/22/complementary-and-alternative-medicine-and-the-nhs/). How much better if we can be more patient focused and have solid treatment to back it up?

Taking a bit more time and care is also the way choice can be offered in a positive way. People want to understand their treatment options, to be consulted and for their wishes to be considered, even if they take the GP or consultant’s word about what it best at the end. It isn’t choice of provider that people want, it’s to be consulted, reassured and to be sure they are getting the best treatment.

So perhaps choice is the wrong word here. Choice is now to associated with provider choice, when it works best when being placed in a respectful and caring consultation. Good GPs and consultants know that already, and get the loyalty they deserve. Trying to put relationships like that on an exit-based, transactional level misunderstands the nature of healthcare.

Complementary and Alternative Medicine and the NHS

August 22, 2011

Complementary and Alternative Medicine (CAM) raises a number of hugely important issues in terms of the NHS. If we are moving toward a more choice-based healthcare system, should funding of it be extended if patients choose it? Why do people often seem to prefer CAM to modern medicine? Should a publicly-funded healthcare system pay for treatments that don’t appear to be backed by high quality research when tested?

Let’s deal with these questions in turn.

The logic of NHS reform, in its present direction, has the stated goal of making healthcare systems more responsive to patient choices, arguing that, for too long, producer interests have dominated the NHS. What patients choose, in collaboration with their GPs, will be funded. The logic of this – let’s call it the consumerist logic, is that if patients want CAM, they should be allowed to choose it, and the NHS should pay for it because the individual patient choice is sovereign.

This sort of thing tends to get health economists who haven’t really got their mental ducks in a row rather vexed. On the one hand, all their instincts tell them that there ought to be free markets and extended choice, but on the other hand, funding treatments such as Reiki, which have next to no evidence base (in terms of published, peer-reviewed studies), makes them very cross. It’s almost as if people were deliberately making poor choices – something that economists get really confused about as we’re all supposed to be informed consumers for their models to work.

Let’s go to the second question – why do some people prefer CAM to modern medicine? I can think of four answers (I’m sure there are more). First, some people will have a predilection for treatments that are based on spiritual or alternative understandings of the world. They may regard CAM as being part of a lifestyle choice that is suspicious of modern medicine, and expect, especially if they are being told to behave like healthcare consumers, that their preferences should be paid for. So ironically, people who are often fervently anti-consumerist demand consumer rights to be anti-modern medicine.

Second, many people who use CAM report a specific condition that it has helped with where modern medicine fell short. I know of sensible people who (or perhaps more powerfully, whose children) have had a chronic condition such as eczema or asthma helped through CAM. According to the standard evidence base this shouldn’t have happened of course, but it does. Now I can’t explain this. It could be that the problem would have sorted itself out (my first daughter’s eczema seemed to disappear largely by itself after it has driven us nuts for nearly a year) or it could be that some other factor got rid of the problem (diet?), or it could be a placebo effect, or it could be the at the CAM worked.

The point here is that all the medical evidence in the world is unlikely to dissuade us from believing that CAM works where it seems to have worked for us, or for someone that we love. In those circumstances, all the criticism it receives may make us even firmer in our belief of its efficacy because we believe we know better. Personal knowledge will tend to trump scientific knowledge where experience appears to have shown us otherwise.

The fourth reason we might prefer CAM is that we are likely to have been given more time and attention that we often receive from our GP. Now that isn’t always the case (at least in terms of attention), but it does have a ring of truth. CAM therapists often do their best to have calming atmospherics and can often give more time to their patient than modern medicine practitioners, who are often pretty pushed. Given this, it’s no wonder that being with a CAM practitioner can make people feel listened to and valued – and that they, in turn, value CAM treatment as a result, regardless of whether what ails them disappears.

Then we come to the final question – should a publicly-funded healthcare system pay for treatment that, when subject to standard clinical tests of efficacy, fall down? Actually, I see no reason why not. The key thing here is that publicly-funded healthcare systems need to be democratically-accountable to taxpayers. If taxpayers want to pay for CAM, we should probably pay for CAM. I don’t really like this conclusion very much (I’m a signatory on any petition to get homeopathy removed from the NHS!), but the thing is this is about democracy, not about efficacy. It only becomes about efficacy if we agree, as a society, that is what we want from our healthcare, and that we won’t fund treatments that aren’t effective. As the public are often prepared to use their own money to pay for CAM, it seems to me there are probably a lot of people out there who would be prepared to sanction taxation-funded CAM.

What does all this add up to? A bit of an mess.

The consumerist logic suggests we should pay for CAM – it’s about patient choice. If the public (collectively) want taxation to pay for CAM, then the democratic argument also points that way. There seem to be lots of reasons why people prefer CAM, and so it shouldn’t be surprising that there is demand for it, especially when it is ‘on the NHS’. But this is the same kind of logic that assumes that people can make good use of choice in healthcare, and I can’t see how this is the case.

This points to an even bigger problem. When it comes to healthcare, most of us know very little. We simply aren’t in a position to judge whether treatments are effective or not. Without a great deal of time and effort, and without a long-term condition where patients may become extremely knowledgeable about their illness, we aren’t good judges of what is wrong with us, and what treatment we should choose to try and get better. Even if we do have a long-term condition, our judgement may be skewed by what we believe happened with particularly treatments rather than any kind of objective, assessable understanding.

As such, we need to assess the claims made by CAM specialists – and writers like Simon Singh have done us all huge favours on that front. But we also need to acknowledge that there are some areas where democracy alone struggles to help us in decision-making. Areas like medicine are complex and demand careful and difficult decisions to be made. Most of us probably wouldn’t make good choices about treatment if left to our own devices, and frankly we need saving from ourselves.

That, however, doesn’t excuse doctors who provide awful service, and who through their lack of caring drive people into the hands of unproven CAM. They need to do better, and to understand that their lack of caring can have terrible consequences – we have to learn from the positive lesson of CAM, that people will often want the most bizarre treatments if delivered in a kindly way.

But what we are left with in the NHS at present is a half-hearted attempt at health consumerism which can’t work because it assumes we are all super-empowered and knowledgeable about both our own health and the healthcare systems we have to navigate, but also a frivolous attitude toward clinical evidence, as we continue to fund homeopathy hospitals. Sometimes compromises can be sweet spots where the best possible outcomes are reached. Here patient choice policies are based on unrealistic assumptions that can’t possibly drive treatment improvements, and the funding of treatments that challenge the NHS more in terms of their service than their actual efficacy. We have to do better than this.

Competition in healthcare and Muir Gray

August 20, 2011

In this recent BMJ blog (http://blogs.bmj.com/bmj/2011/08/19/muir-gray-competition-between-systems-for-pride-is-effective-and-essential/) Muir Gray suggests that, instead of using market-based competition, we need instead pride-based competition ‘between systems accountable to defined populations. The luminaries of the business world have now joined the call for this approach, and there is evidence to support it…..Perhaps it is better to leave it to the professionals and patients to create the system and the networks cooperatively, just like the ants do’.

Using screening as an example, he shows how professionals responsible for those systems will ‘naturally compete with one another on quality, outcome, and the use of resources. Their feedback offers opportunities to improve quality and safety, their suggestions offer opportunity for redesign, and they would want their system to be the best: co-ownership is effective’.

I think this approach is a key intervention in the debate around the use of markets and competition in healthcare, and I encourage everyone who is interested in this debate to read it in the original. I’ve tried my best to represent it above, but necessarily can’t for length reasons.

However, I’m not sure Muir Gray is quite right. First, in terms of the presumption that we can come up with an indicator that can be universally agreed and competed upon (such as standardised detection rate in his screening example), and second in terms of the unintended outcomes I see resulting from his suggestion. I want to suggest, however, that he is going in a far better direction in terms of reform, however, than market-based competition.

What Muir Gray is suggesting is a different form of competition than market-based competition, and using the world ‘competition’ tends to conceal that. This matters because suggesting that clinical systems foster internal pride-based competition has a lot to commend it, but can only work if those system work in a very different way to those where those clinical networks are competing in markets. In markets, sources of advantage quickly turn into commercially confidential secrets, the collaborative ethos he has in mind is in danger of quickly being undermined.

Equally, his example works because of its deliberate use of a fairly straightforward (relatively) clinical system. However, most clinical systems can’t be reduced to a single indicator in the way his example appears to be, but that won’t stop health economists from trying.

I’d like to make a few amendments.

First of all, what Muir Gray is referring to shouldn’t be called competition – that term is now to associated with market-based logic. Let’s call it something else. Quality bechmarking – anything but competition.

Second, let’s put in place a system where clinicians agree appropriate measures of clinical systems from the bottom-up. The QOF seems to have worked because GPs bought into the measures, and a large part of this is that they had a voice in deciding them. What we need are evidence-based measures against which the professions are prepared to work with, and which are themselves reviewed and set against the best practice in the world.

Third, achievement against the measures needs to be accountable to outside the system, and there needs to be a link between those overseeing the system and democratic bodies. I’m concerned about how ‘insider’ his model presently appears to be. If all clinicians are so committed to improving things, how come they all aren’t using the best practices? I’m not as hard as Alan Maynard on this, but he does have some good points about how poor clinical practices are often far too tolerated.

Fourth, we need to make a big deal out of those that perform the best on the range of clinical measures. Most importantly, we need to learn from them to raise the bar for those that aren’t as good. We also need to look at the poorest performers and be clear about what the problems are and what we are going to do about them.

I’m not wild about the potential for league-table creation that will come from the creation of these measures, preferring instead to think about creating mechanisms for what we can learn from the best. However, it is imperative that health organisations are held democratically to account and these measures necessarily will form a part of that process. I favour local health organisations being far more accountable to local authorities as trying to deal with this problem nationally breaks the link between democratic accountability and the specific organisations we need to explain themselves. But we will need to achieve a far higher level of local debate around healthcare to achieve this.

We will need to make sure that health systems are held to account for driving up the standards in their areas as a whole – this would be the job of national government. National government, in turn, would be accountable to the public for resourcing that system and for its overall performance.

My concern with the Muir Gray approach then, is that I’m worried it will create the room for more market-based competition because of its use of the term ‘competition’ (and words do matter), with this single measure approach potentially being subverted into a proxy which could be used in a marketplace instead, and I’ve made clear elsewhere in this blog why I think that is a bad idea. I’m also concerned because it doesn’t link into democratic institutions in any obvious way.

However, I think this intervention is amongst the most sensible and workable we’ve seen in the debate. As such, we have a great deal to thank him for.

Irresponsibility in healthcare media coverage

August 18, 2011

Healthcare makes for great media stories. We have a range of archetypes about doctors and nurses especially that stories can tap into, and medical science can sometimes do things which are truly extraordinary, giving a sense of wonder.

However, there are also example of irresponsibility in media coverage. I’m not going to pick out specific pieces, but if you have any interest in healthcare you’ll recognise the kind of thing that I’m talking about.

Irresponsible story type one might be the account of the patient denied treatment by the evil bureaucrats. This can take a number of forms from surgery not being funded (often associated with obesity) or drugs not being paid for (especially true in newer treatments).

Let me be clear, these stories often involve personal tragedies – it’s obvious why the individuals want to let the press come and see them to cover their case, and it presents an opportunity for journalists to show how compassionate and outraged they can be. However, these stories are also irresponsible in that they completely decontextualise the decision not to fund care, and present that decision in a manner which makes healthcare managers out to be monsters.

Decontextualising funding decisions means that these stories appear to be personal attacks on vulnerable individuals. They ignore the fact that healthcare budgets are limited, and so funding one treatment often means not funding another. We’d all like to treat every person with the operation or drug that they want, but we can’t. That means that we have to try and come up with principles by which we decide who gets funding and who doesn’t. Ignoring the principles in reporting, not bothering to find out what they are or why they have been chosen, is lazy and irresponsible. Not explaining that treatment decisions have consequences is too. We are left with evil health managers refusing to pay for care – and the situation is simply not that straightforward.

Irresponsible story type two is the evil doctor. This has got a lot worse in recent years, but follows a similar path to that of the patient denied treatment.

An individual who has had surgery that has gone wrong, or drugs that have reacted badly, discusses their pain or ongoing problems, and the doctor who treated them is portrayed as being careless or uncaring or incompetent. Now a small number of doctors are those things I’m sure, but the problem is that media coverage simply doesn’t deal with that – it is as if suddenly the whole of the professions are engaged in a cover-up. Raymond Tallis’s wonderful book ‘Hippocratic oaths’ has a range of cases where trial by media occurred, and it doesn’t make for uplifting reading.

Of course doctors who have made mistakes need to be held responsible for them, and to learn from them, but the way we increasingly pillory every error, even from those with otherwise blameless records, isn’t constructive, and isn’t responsible. If I have a bad day in the office the worst that can happen is students don’t get taught as well as they might have. For clinicians the stakes are far, far higher. I’m frankly in awe of people who can operate at the high level most clinicians manage the vast majority of the time.

However, the overwhelmingly high performance of most clinicians gets missed out of accounts of accidents – it’s much better it seems to report things entirely from the patient’s perspective. A voice about pain and suffering deserves to be heard, but in a context where a clinician’s good as well as bad appears as well.

It is little wonder that it is so hard for us to have a rich public debate about health and healthcare reform when we are fed stories from the media of such poverty. We all need to do better – the media in trying to portray healthcare stories in a more balanced and careful way, readers in not accepting bias and carelessness in reporting, and those of us who are trying to take a public interest in healthcare to call media, clinical and patient irresponsibility when we see it. We desperately need a higher level of debate around healthcare – it is all of our responsibility to achieve it.