Leadership in healthcare and the NHS bill

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

I think I was wrong.

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

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

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

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the numbers of those at the meeting who believe it will damage patient care (89%), or who believe the bill should be withdrawn (79%) say a great deal.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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The research on NHS competition – evidence, rhetoric and empiricism

In a piece published here in the FT on February 21^st and available at http://www.ft.com/cms/s/0/5a996db2-5c93-11e1-8f1f-00144feabdc0.html#axzz1nCFZ4BWd, but behind a paywall you have to at least register to access) Le Grand and Cooper suggests that the argument over the future of competition is a case of, following Ayers, ‘empiricists’ versus ‘intuitivists’ with the latter becoming ‘crowded out’ and their evidence of competition improving the NHS being ignored.

They go on to say that patient choice was introduced in 2006, and four studies based on hundreds of thousands of patient observations have clearly and consistently shown that ‘public hospitals facing more competition from other public hospitals improved their outcomes and became better managed’ and that ‘the introduction of competition in the NHS could be credited with saving hundreds of lives’.

They write that many of the principles in the NHS bill were sound, but the debate around the bill has empowered provider interests and the intuitivists who have made unsupported claims that have led to dead-end debates, and the ‘robust evidence base’ for competition being likely left on the cutting room floor.

There are a large number of problems with their argument.

First, there is more than one way to do empirical social research. Le Grand and Cooper seem to be saying that the methods they like, predominantly large-scale regression-based models, are the right way. The imply that theirs are only methods which are robust and so the only ones upon which evidence should be based. They seem to be suggesting that they have announced their findings on competition in the NHS, and that they are definitive.

The empirical parts of the findings from the research by Cooper, Propper and others are important – they suggest the NHS has seen changing referral patterns and increases in quality in particular locations. But they do not make any empirical link between these findings and competition, rather they assert rather than demonstrate that NHS hospitals faced competition after 2006, and so their results must be due to that change.

But their work takes no account of empirical research from other disciplines that finds those working in hospitals being largely disinterested in patient choice or competition because they already have waiting lists and see little benefit in competing for more patients. Equally, it makes no attempt to explain exactly how their empirical findings came about.

A more open-minded approach to considering the health reorganisations of the 2000s tends to regard the introduction patient choice and payment by results as one of many changes, so it is near-impossible to attribute the outcomes found in their research to a single factor. It is not enough to simply assert that competition appeared in 2006. Surely an empirically-driven research project would seek to explain not only what happened after that date, but how. We do not dispute the empirical parts of their work, but we do think that the claim that those changes occurred due to competition are at least contentious, and probably mistaken.

For competition to have caused the changes found in the research Le Grand and Cooper favour, even in the most stripped down and unrealistic form, two things must have happened. First, that that the introduction of patient choice plus payment by results led to competition, and second that competition is able to drive up clinical quality. They don’t show either, but rather assume both.

It is hard to see how choice plus payment by results equals competition. A general point is that economic theory itself tell us that market structures with only a providers, as is the case in the NHS, are more likely to be collusive than competitive with little incentive to improve quality. Empirically, it is hard to say how the introduction of patient choice led to hospitals competing. Only around half of the patients surveyed after the introduction of choice even remember being offered it to them and only a tiny proportion made use of the NHS Choices website specifically launched to help them make them in an informed manner. Even where patient choice was both in place and informed – so that patients chose shorter waiting time and better performing hospitals – the hospitals they did not choose faced little in the way of penalty provided they were able to keep their demand levels stable from other patients waiting for treatment.   A shortage of demand does not seem to be a problem in the NHS (or why do we spend so much time worrying about waiting lists?), and unless patient choices lead to real financial problems for hospitals not chosen, the causal link is broken.

Can competition drive up clinical quality? To assert this assumes that those working in hospitals have both the motivation and the means to respond to falls in demand especially by improving care. Provided local areas have sufficient demand for a hospital’s services, there seems to be little motivation to react to patients choosing to go elsewhere. Even if hospitals do face financial pressures, it doesn’t seem to be the case there is a threat of closure – a mere two weeks ago the government gave a £1.5bn bailout to 7 hospitals in financial trouble over their PFI contracts.

Different groups of workers in hospitals also respond differently to the threat of losing patients through competition, even where we assume it to be present. Managers, who may be on performance-related contracts, will regard them as a more serious threat, and yet raising clinical standards requires manager to get clinicians to improve their practices. Empirical research over decades suggests that it is pretty difficult for managers to get clinicians to do things differently in the best of times. Simply assuming away this problem as an inevitable consequence of competition seems rather extraordinary – and completely ignores detailed work carried out by researchers who believe there are considerable problems with the underlying research upon which these claims were based, and which we published in the Lancet.

What this leaves us with is the view that Le Grand and Cooper are dismissing those that don’t use their methods, or believe in their particular kind of economics, as ‘intuitivists’. This is rather closed-minded, and a little odd as the data they use wasn’t collected through their own personal observations, and seems to be have been interpreted according to their own theories rather than the more inductive approach which is at the heart of Ian Ayers’ book (which I included myself in my recent book on research methods (http://www.amazon.co.uk/Designing-Social-Research-Guide-Bewildered/dp/1849201900/ref=sr_1_1?ie=UTF8&qid=1330159375&sr=8-1) as making a range of interesting contributions

There is more than one way to do empirical social science. There is more than one way to explain research findings. I’d like to invite Le Grand and Cooper to be rather more open about their assumptions and to regard their findings as the beginning of a discussion about evidence for NHS reorganisation, rather than, as they seem to be believe, the final word.

Social enterprises and community care

There is a thoughtful piece in the Guardian healthcare network by Allison Ogden Newton about social enterprises and community care (at http://www.guardian.co.uk/healthcare-network/2012/feb/23/nhs-reform-capital-overshadows-debate).

I think it is clear that there is a consensus that we need more community-based services to prevent un-necessary hospital admissions, to treat patients more appropriately.

I will also agree that in order to foster innovation, we need new community-based organisations to work with the NHS as it requires fresh perspectives and new ways of doing things to find new answers.

However, I disagree that competition is necessary to achieve this. I also have concerns about the NHS relying on non-public provision for the long-term delivery of services.

It isn’t necessary for new organisations providing care for the NHS to be competing with other providers of care. We can do this just as we co-operatively. The NHS can buy care from social enterprises and other non-public bodies without the need for them to be competing with one another. I have no problems with the idea of such services being commissioned, and their impact and effects evaluated through careful research.

Equally it seems to me to be unwise, either for social enterprises or the NHS, for non-public providers to become dependent on public funding. It’s a bad idea for the NHS in case those providers run into financial difficulties, and which will result either in them having to be bailed out by the government, or patients face the disruption of having to be reallocated to other providers, possibly in systems which don’t have the spare capacity to support them.

It also seems like a bad idea for social enterprises to become dependent on public funding – their vibrancy is surely based on being able to be sustainable without becoming dependent on the state. If social enterprises are dependent on the state for financing, they might as well be public bodies. The private health sector is, I read, already getting 25% of its revenues from the public purse, so effectively sustained by it. That doesn’t strike me as being healthy for either public funders or private companies, and repeating the error with social enterprises would be short-sighted.

My suggestion then would be a more research-driven approach – asking social enterprises to provide services to the NHS which would be evaluated, and if successful, rolled out across the system, but funded publicly. There is no intrinsic reason why public funding should prevent innovation – that’s about good management, and there’s no intrinsic reason why good management only exits outside the public sector.

More on competition in healthcare

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

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

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

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

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

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

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

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

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

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

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

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

I confess I still don’t really know.

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

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

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

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

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

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

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

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

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

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

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

Okay, so what else could it be?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why no top-down NHS reorganisation will work – the hubris of policymaking

“We’re an empire now, and when we act, we create our own reality. And while you’re studying that reality — judiciously, as you will — we’ll act again, creating other new realities, which you can study too, and that’s how things will sort out. We’re history’s actors . . . and you, all of you, will be left to just study what we do.” – Senior Aide to George Bush, at http://www.nytimes.com/2004/10/17/magazine/17BUSH.html

The government promised us in the last election that there would be no top-down reorganisation of the NHS. I think in their own world that Lansley, Cameron and Clegg may have started out believing that the present reforms weren’t ‘top-down’ – that they were about passing responsibility (and control) over funding down to GPs, so creating a kind of bottom-up change (albeit one implemented in a top-down way)

But I’d like to refer to a phrase other than ‘top-down’ in that last sentence – the ‘in their own world’ bit.

I’d like to start from the assumption, which I actually believe, that politicians genuinely want to do good (no sniggering at the back there). They then construct plans to try and make the world better, but of course start off with their own prejudices and beliefs, and work out from there.

More than that, politicians tend to hang about with, and listen to people, who support their prejudices and beliefs. This is perhaps why it’s so dramatic when blogs like Conservativehome come out against the NHS reforms (http://conservativehome.blogs.com/thetorydiary/2012/02/the-unnecessary-and-unpopular-nhs-bill-could-cost-the-conservative-party-the-next-election-cameron-m.html) – we expect political parties to be homogenous places (but don’t worry – here’s Baroness Warsi to make it all better (http://conservativehome.blogs.com/platform/2012/02/sayeed-warsi-torychairman-as-conservatives-it-is-our-duty-to-support-the-nhs-bill.html).

The internet makes this tendency worse. A range of commentators have pointed out that we now have unparalleled ability to only see the news we want to see, with our prejudices built in. Jaron Larnier (http://www.amazon.co.uk/You-Are-Not-Gadget-Manifesto/dp/0141049111/ref=sr_1_1?ie=UTF8&qid=1329475840&sr=8-1) shows how this can stifle inventiveness and deaden our social interactions with others – because we don’t have to engage with those we disagree with, or work out how to argue with them.

Now – the quote with which this piece began. Imagine you’d been in a political party for years, never really had to engage with others outside of your own views (except for those tedious electoral campaigns, but even then, if you have safe seat you don’t see too many of them), you had the Institute of Economic Affairs talking such extreme nonsense (http://www.iea.org.uk/blog/how-to-abolish-the-nhs) that they make you feel moderate, and you find yourself to be Secretary of State for Health. Not only have you not really been much exposed to detailed debate about a topic, but you also now have power. In these circumstances you might believe that you genuinely can ‘create your own reality’. You’ve studied the NHS. You know what’s wrong. And you’re going to fix it.

So you prepare your plans, you publish them. The first battle is getting them into law. That means that other people pay attention to your proposals for the first time, and they start objecting. You make assertions which are taken as common-sense in your own community, but you find out that others don’t share them.

That gives you a choice. You can either begin to seriously question the common-sense you and your communities hold, or you can try and get the plans through by giving away a few concessions, or even try and just bluster through. More often than not, your plans eventually get to become law, even though you might be dead wrong, because you can rely upon the whips in Parliament, and because you are the majority government. Second chambers can be a pain to get your legislation through, but in the end, you can over-rule them.

Then comes the really tricky bit. You then have get people who have been campaigning against you to implement your reforms. The best you can do is to include the legislation game-changing alterations that mean that the whole structure of your reforms force people to do things differently. The disastrous rail reforms of the mid-1990s are a good example of this – they tried to create competition when there really could be none, and did nothing to address under-investment in rail infrastructure – something that was only really faced up to after some appalling rail disasters.

The NHS Bill goes some way to forcing people to do things differently. PCTs are abolished and CCGs will be given their responsibilities. The boundaries between public and private providers will get blurrier (at least, until, the latter either go bankrupt or leave the NHS again). However, having created so much anti-feeling amongst NHS workers, an awful lot of people now have a stake in undermining the reforms. They won’t (I hope and believe) undermine patient care, but there is certainly scope for undermining the introduction of market forces through local collaborative agreements, and of using commissioning to similar ends.

But what this shows above all is the hubris of policymaking. It is hubris to imagine you can, as a new government, change public organisations from top to bottom and expect everyone within them to go along with your plans, and for them to work. To assume you know better than those working in public services how they should be organised and delivered.

That’s one reason why top-down NHS reorganisations don’t work, but I’d go further and say they can’t work. Policymakers are too closed off from viewpoints other than their own to have to talk through their ideas properly. But more importantly, there is no right answer to NHS reform that can be imposed from the centre. We need greater plurality and local adaptation for health services, and much stronger local democratic links. We can have national standards but allow local areas to work out or adapt how to achieve them best for them. Top-down plans won’t work – they are hubris.

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

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

Mmmm.

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

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

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

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

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

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

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

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

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

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

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

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

A brief FAQ on the NHS bill

A brief FAQ on the proposed changes to the NHS in England. I’ve done my best to strike a balanced voice, but apologise if cynicism takes over at various points. Equally, I’ve tried to cover lots of ground in as short a space as possible, but this necessarily means missing some things out.

1. How exactly is the bill going to change the NHS?

Well it’s complicated (!). In principle, the bill will abolish Primary Care Trusts (which purchase care as well as providing some of it at present in community health services), and replace them with GP commissioning groups instead. It will also shrink the number of Strategic Health Authorities and increase the potential involvement of the private health sector in the NHS both in terms of provision, but also in terms of offering advice to the new GP commisioners. However, the bill’s amendments have resulted in commissioning organisations having several tiers of management – possibly meaning the whole thing will be more bureaucratic than before. Equally, the benefits of extending private provision are contested (see below). Finally, the argument is that commissioning groups will mean a smaller role for the Secretary of State. Many of those against the Bill have argued that this means the Secretary of State will no longer responsible for the NHS, which could create something of a democratic gap, and have sought assurances that this will not be the case.

2. Why ask GPs to purchase care for their patients?

Advocates of this system say that GPs are closest to patients and so know what they want. Those against wonder why we are asking people whose primary job is to care for people to do something related, by very different (like asking a pilot to design and purchase an aeroplane). Equally, the bill’s opponents are often concerned that by making commissioning bodies smaller, they will not be able to pool risks. What this means is that those who need the most expensive treatments will take up a bigger proportion of a small commissioning body than they would if there was a big one, with a bigger budget. Small commissioning bodies should be more responsive to their particular community’s needs, but have a smaller total budget, and so a reduced ability to pool risks. This at least theoretically, has a problem that where a community has a disproportionate amount of expensive illness, their commissioning body might run out of money. A bigger commissioning body is better able to pool risks, and so is less likely to be affected by a disproportionate amount of expensive illness, but is less able to be sensitive to particular communities.

3.Why make greater use of competition?

Advocates of competition claim that there is evidence that it has saved lives since patient choice was introduced by Labour in 2006 (as in http://blogs.independent.co.uk/2011/04/10/competition-in-health-care-saves-lives/). This research was picked up by the government, and appears to have been used by them to legitimise and justify the reforms. Andrew Lansley has suggested that competition will act as a spur to medical innovation as well (HSJ piece).

Those who disagree have written pieces showing this research is, in their view, flawed (http://www.lancet.com/journals/lancet/article/PIIS0140-6736(11)61553-5/fulltext (where there is are responses from the authors and the critics as well). The responses to Lansley’s piece above suggest his view is not without dissenters.

4. Will making greater use of the private sector improve the NHS?

Those in favour say it asks as a spur to driving up standards and reduce waiting lists (http://m.hsj.co.uk/5040671.article). Those against argue that they’ve already seen private sector disasters like Southern Cross, PIP and that there are other big problems as well (https://t1ber1us.wordpress.com/2012/02/10/the-problem-of-the-private-sector-in-nhs-reform/).

5. What about if hospitals or other providers fail (go bankrupt) in the new competitive marketplace?

The government have put together a ‘failure regime’ in the NHS bill to try and deal with this. Critics argue that it is unlikely that large healthcare providers will be allowed to ‘fail’ (closing NHS facilities has always been politically contentious, and finding sufficient capacity to take all the patients from a large provider is unlikely), and that non-public providers will simply form sub-companies, limiting their explosure and commitment to providing NHS care (as happened, for example, in the failed East coast mainline franchise). It is possible private organisations could be asked to take over failing NHS organisations (as has happened at Hinchingbrooke hospital), but then that would potentially leave taxpayers ‘on the hook’ should they run into trouble, and it proved impossible for them to be closed.

In sum, unless healthcare providers are allowed to fail, it is hard to see how market-based incentives can work, and it is hard to see how big providers can be allowed to fail.

6. What evidence is there in favour of the reforms?

The government have repeatedly claimed that their reforms are evidence-based, based mostly on the competition-based research discussed above. There are pretty strong refutations of the evidence underpinning the reforms from Ben Goldacare at http://www.guardian.co.uk/commentisfree/2011/feb/05/lansley-use-word-evidence and from Chris Mason at (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html).

7. How much will the reforms cost?

The government originally claimed that the reforms would cost about £1.5bn. However, claims from others vary widely up to about £4.5bn at the top. In either case, the NHS needs to find savings of around £20bn in the coming years, and the costs of the reform add further to the savings needed. The government argue that the reforms will make the savings more attainable. Opponents wonder at the sense of undergoing significant structural reform at a time when the NHS is trying to find savings.

8. If the reforms don’t work out, can we just get rid of them?

Competition law means that, once areas of public service have been opened to non-public competitors, it is very difficult to remove competition subsequently. This may mean that the changes may be irreversible.

9. Why are we reforming the NHS now?

The government argues that the NHS needs to make £20bn of savings, and so major reforms are needed to achieve that goal. Those against the reforms wonder how you can change an organisation so much and still expect it to save money, and ask why the NHS reforms weren’t publicised and debated in the 2010 General Election if the Conservatives knew they were going to do this (the White Paper was published just six weeks after the government was formed).

10. Who supports the bill, and who is against it?

The BBC have a good list of clinical organisations at

http://www.bbc.co.uk/news/uk-16954223

Newspapers of the left (for example, the Guardian), have argued against the reforms for some time. In recent weeks, more right-of-centre publications such as the Spectator (http://www.spectator.co.uk/coffeehouse/7642848/lansleys-battle-shouldve-never-been-fought.thtml) have argued that the bill is becoming a liability, and the ConservativeHome website also published editorials against the reforms last week (http://conservativehome.blogs.com/thetorydiary/2012/02/the-unnecessary-and-unpopular-nhs-bill-could-cost-the-conservative-party-the-next-election-cameron-m.html).

There are media voices in favour of the Bill (John Rentoul of the Independent seems to support at least some aspects of it (see http://www.independent.co.uk/opinion/commentators/john-rentoul/john-rentoul-lansleys-bill-is-safe-but-he-is-not-6785686.html?origin=internalSearch).

11. Is it too late to not go ahead with the bill now?

The NHS is already some way through implementing the changes contained in the bill, and it will be difficult to go back to how things were in 2010 – staff have been made redundant, building leases sold off. However, commentators and academics have proposed a ‘Plan B’ including this one from Kieran Walshe http://www.guardian.co.uk/commentisfree/2012/feb/01/nhs-reform-plan-b

Eight myths about NHS reform

On Sunday 12^th February I tweeted eight myths about NHS reform. Here they are again, by popular request, in one posting:

Myth one: Healthcare in the UK is unsustainably expensive. No it isn’t – compared to other countries it’s not expensive en.wikipedia.org/wiki/List_of_c…

Now I got lectured on twitter for posting a link to Wikipedia, but this isn’t a research paper and I was looking for a good visual representation (provided someone hasn’t defaced the page) that the UK is, compared to its economic position, not a big spender on healthcare. And bear in mind that we spent a great deal less than this before 2000 or so. Here’s a link to the OECD provided by @Andrew2186 which pretty much confirms the point http://www.oecd-ilibrary.org/sites/health_glance-2011-en/07/01/g7-01-01.html?contentType=&itemId=/content/chapter/health_glance-2011-60-en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2011-en&mimeType=text/html. Finally, bear in mind that this is total expenditure, both public and private, so comparisons are difficult – but in total terms the NHS is still good value.

Myth two: Competition has made things better and ‘saved lives’.

No it hasn’t

lancet.com/journals/lance…”

This is important because the government have frequently cited research from the LSE claiming to show ‘competition saves lives’. I really don’t think this work stands up to scrutiny. You’ll find other posts about this topic on my blog.

I have been asked to post the reponse the authors of the research made to these criticisms. They are here:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61708-X/fulltext

And the response of the critics is here:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61890-4/fulltext

What all this shows, for me, is that something that is being trotted out as a fact (‘competition saves lives’) is actually pretty contentious. If the government’s arguments rest on this research, it is not, for me, solid ground.

 

Myth 3: It doesn’t matter whether public or private sector provides healthcare.

It does:

t1ber1us.wordpress.com/2012/02/10/the…”

This posting links to another page in this blog. The standard assumption most economists have is that it doesn’t matter whether providers are public or private – but it does. We can’t let major healthcare providers fail (as in go bankrupt). This has profound consequences for the way any healthcare market might work.

Myth four: Buying or choosing healthcare is just like going to a coffee shop.

It isn’t

t1ber1us.wordpress.com/2011/08/02/why…

Again, this links to another entry in this blog. You might think it is an odd thing to try and refute, but there are clinicians out there claiming that choosing healthcare is just like a coffee shop. No, really.

Myth five: Those who oppose #nhsbill oppose all reform.

No we don’t:

t1ber1us.wordpress.com/2012/01/25/non…

The argument often made is something like this. The NHS needs reforming. This is a reform. Therefore those who oppose this reform oppose all reform. This is silly. Here’s my attempt to provide an entirely different set of reforms.

Myth six: The#nhsbill is supported by those working in the NHS.

No, most oppose it.

bbc.co.uk/news/uk-169542…

The BBC’s coverage of the reforms has often been sadly lacking – putting up people claiming to speak for clinicians in favour of the bill, when they are often in a small minority. However, the website above gives a sense of who is in favour, and who against, the Bill. Most are against.

Myth 7: The#nhsbill will streamline management and reduce bureaucracy.

No, it won’t.

abetternhs.wordpress.com/2012/01/31/scr…

It’s interesting to track how the justification for the reforms has changed almost completely in the last year. The latest myth is that it will streamline management, and cut back on bureaucracy. The problem is that the reforms will probably do the opposite.

Myth 8: It’s just lefties that are against the #nhsbill.

No, many Conservatives don’t like it either.

conservativehome.blogs.com/thetorydiary/2…

In the last few days several Conservative commentators have suggested they think the bill is a disaster.  Here’s the Spectator (hardly a bastion of Labour support that is also critical http://www.spectator.co.uk/coffeehouse/7642848/lansleys-battle-shouldve-never-been-fought.thtml).