The NHS reforms as bullshit

In this piece I’m going to claim that the NHS reforms represent bullshit. You might think that’s a bit strong, especially from someone who’s meant to be an academic and all, but hang on a moment and I’ll try and be clear what I mean.

First, I’ve got to say what bullshit is. Surprisingly perhaps, the US philosopher Harry Frankfurt has written on this – a rather wonderful essay you can buy on Amazon called, succinctly enough ‘On bullshit’.

Frankfurt argues that bullshit is different from lying because the latter has some regard for truth and falsity. Lying is where you arm…lie. But to be able to lie, you’ve got to know what the truth is, so you can avoid telling it. Equally, truth-telling is when you tell the truth.

Bullshit is where you don’t really care what’s true or false but go ahead and make a bunch of claims about what’s true anyway. It is claiming to be truthful when you don’t know what’s true (or following the above, what’s false).

Now the NHS reforms (to return to our topic) seem to show a remarkable tendency towards bullshit.

Those of you with a long memory will recall that the government made lots of claims in the early days of the reforms that they were evidence-based. A year ago Ben Goldacre showed us this wasn’t the case (http://www.guardian.co.uk/commentisfree/2011/feb/05/lansley-use-word-evidence).

Later on, there were a bunch of claims that the NHS needed reforming because of its dire state. Chris Mason has had a look at the claims that were made, and again shown them to have no grounding in reality (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html)

A great deal has been made by the government of research from the London School of Economics which doesn’t actually have much to do with the reforms, but does suggest that competition between providers leads to a reduction in mortality (or to put it another way, as they did in an earlier working paper, ‘competition saves lives’). When you look at that research, however, there are serious problems as I’ve written elsewhere in this blog as well as in a piece I co-wrote with Allyson Pollock and others in the Lancet (it’s here

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961553-5/fulltext, but sadly behind a pay-wall).

And then, of course, both Cameron and Lansley have repeatedly claimed that they have the support of the medical profession for their reforms. This has never really rung true, and yesterday the joint editorial from the Health Service Journal, British Medical Journal and Nursing Times (http://www.hsj.co.uk/comment/leader/the-nhs-deserves-a-better-more-open-debate-over-health-reform/5040868.article) certainly seemed to show that there isn’t a great deal of support, as do opinion polls on the matter.

Finally, we have the attempts to amend the Health and Social Care Bill that have resulted in no-one even understanding exactly what is going on. The beast is truly out of control, and claiming to have any understanding of what its effects will be is to be out of touch with reality.

Now it would be quite possible to suggest, given the above, that the government have been lying to us. I don’t think that is the case. But I do think that the NHS reforms represent bullshit as I described it above.

I think that the NHS reforms are an example of a government which has got itself into a terrible mess to the point that they no longer care whether what they are doing will work, or if it bears any resemblance at all to their original White Paper plan (which has a kind of coherence, even if it, in my view, was never going to work). They’ve lost all track of reality, all sense of whether what they are saying is true or false any more. The NHS reforms are, therefore, bullshit.

I’ve written elsewhere here about what we ought to do instead, as have Roy Lilley and Kieran Walshe (the latter at http://www.guardian.co.uk/commentisfree/2012/feb/01/nhs-reform-plan-b). But would like to raise one more problem.

The problem is that all big-scale NHS reform is bullshit because it requires policymakers to pretend they know what will happen when they really have no idea. No large organisational reform is going to make things better because it will not be about making things better (which involves, invariably, finding ways that clinicians can look after their patients better), but instead imagining that centralisation or decentralisation or markets or bureaucracy or commissioning or abolishing commissioning or something else, will somehow improve things. It won’t. There is not right or wrong organisational structure. This is a category error – it’s confusing changing organisational forms with improving healthcare. There may be a tenuous relationship between the two, but that’s all it ever can be. Clinicians might do their jobs marginally better in one organisational form than another, but there’s a reason why patients seldom notice NHS reform no matter how big – it’s because they experience the NHS not through its organisational reform, but in their relationships with clinicians (and the teams that support them).

Finally, I’m afraid, looking for evidence (as some people seem to want to) about large-scale NHS reform to decide ‘what works’ and what doesn’t, is also bullshit. This is because you can’t find out what’s true or false about organisational forms – the same category error as I’ve mentioned above. There will be good GPs providing great care in resource-starved, crap premises in poorly-integrated health systems, and crap GPs providing awful care in resource-rich, excellent premises in highly-integrated areas. There isn’t an organisational solution that is intrinsically right and supported by any kind of sensible evidence. Healthcare is about people, not organisational structures. We can do our best to avoid putting clinicians in impossible situations, but it seems to me that the present NHS reforms seem more likely to make their job more difficult by asking GPs to be commissioners (rather than, say, GPs) and by asking healthcare providers to compete with one another rather than provide better care.

So, there we go. These NHS reforms are bullshit. Trying large-scale reform the NHS is bullshit. Imagining there is evidence about organisational reform is bullshit. What is left is the hard work of making healthcare systems work better through the careful use of clinically-driven standards and targets, by not accepting poor performance against those standards, and by remembering that all of this is meant to be democratically accountable to us, the people. It’ll be a long hard road. But if you wanted to do something easy, you should have become a quantum physicist.

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7 Responses to “The NHS reforms as bullshit”

  1. The Jobbing Doctor Says:

    Thank you for this cogent piece, Ian, that chimes in nicely with what I have felt for many years.

  2. gpprotest Says:

    I am a GP in Tower Hamlets. Many thanks for your post. Yes, I agree that much of all of this is bullshit. The use of words like ‘Choice’, ‘Modernisation’, ‘Quality’: many of the health ministers’ statements contain these words, as do statements by Department of Health spokespersons. My feeling is that any time these people use sentences with these words, it is important to turn on the bullshit detector.

    Yes, the word ‘bullshit’ might seem a bit shocking, but the level of deception requires it. What if it were used more openly, with a clearly defined meaning, in this debate around the Health Bill?

    We need much more analysis of the ways in which the politicians tell lies, mislead, and attempt to deceive: your post is a welcome contribution.

  3. John Coakley Says:

    For reasons that are completely incomprehensible, those charged with the stewardship of the NHS always focus on structural reform. This is unlikely to alter function. If we were to adopt an approach that defined (clinical and lay approved) quality standards, measure them and publish the results, we would be making a good start.

    Function, not structure.

  4. Susan Says:

    as someone with a Physics degree I agree these reforms are minefield but sadly with a simple likely outcome of ……up the NHS

  5. Simon Says:

    Great post Ian. Politicians interfere because thewy think they have to. They are not experts. They are advised by others who are not experts either but who often have vested interests. They also fear ther simple notion of the public merely wanting good health care free at the point of use and instead complicate this truism by talking about choice, which is in fact, an issue deeply mired in bullshit. Only about 7 per cent of the population want choice in education, and I suspect the same applies as regards healthcare.

  6. John Gabbay Says:

    Yes it’s bullshit in the sense that it’s not deliberate lying, but maybe there is also an element of deliberate deception, or at least obfuscation in the loose and misleadign way Lansley and the others use their language about the “reforms” (where even that word is an euphemism for “total shambles of an upheaval”. See John Lister’s brillant and very funny http://www.healthemergency.org.uk/pdf/TeachyourselfLansley.pdf

    • Ian Greener Says:

      Hello John. I’d like to believe our politicians are suffering from some kind of theory-blindness (in Kahneman’s terms) rather than deliberately misleading us. I tink they’ve worked out what they think is the right thing to do, got some evidence around it (which may have helped make up their decision) and are genuinely baffled that others think differently – then they see they are other arguments, panic, and go into defensive mode. Something about politics being incredibly insular perhaps so you don’t hear dissenting views until you’ve made your policy public?

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